2019-2020 Registration

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210 S. Morgan Avenue. Broussard, LA 70518. (337) 837-1112 FAX: (337) 837-3728. Lisa Ledet, Director. 2019-2020 Registration ... Child's Doctor: ...

First Baptist Church Mother’s Day Out Program 210 S. Morgan Avenue Broussard, LA 70518 (337) 837-1112 FAX: (337) 837-3728 Lisa Ledet, Director

2019-2020 Registration Child’s Name: ____________________________________ Birthdate: _____________________ Sex: ______

Mother

Father

Name Street Address City, State, ZIP Phone # Email Address Employer Work Phone # Parents’ Relationship to Each Other: ⃝ Married

⃝ Divorced

⃝ Separated

⃝ Single

(If divorced, a copy of the Divorce Decree noting guardianship, days of visitation, etc., must accompany this form.)

Child lives with (please check all that apply): ⃝ Mother and Father ⃝ Mother ⃝ Father

⃝ Other

If other, please describe _____________________________________.

Please check preferred days: Monday _____ Tuesday _____ Wednesday _____ Thursday ______ Registration Fee (Non-refundable): $75.00 Monthly Tuition: 2 days per week - $185.00 / 3 days per week - $245.00 / 4 days per week - $295.00 Curriculum Fees: 2 year olds - $40.00 / 3 year olds - $50.00 / 4 year olds - $70.00

Optional Information: Family Religious Preference ______________________________________________ Church Membership________________________________________________________________________ How did you find out about our program? ______________________________________________________

(Front)

First Baptist Church Mother’s Day Out Program 210 S. Morgan Avenue Broussard, LA 70518 (337) 837-1112 FAX: (337) 837-3728 Lisa Ledet, Director

I understand that my child will only be released to the parents listed on the front of this form and to the individuals listed below. I understand that this list can be updated as needed throughout the school year. Individuals listed will be required to show identification. THESE INDIVIDUALS MAY ALSO BE CONTACTED IN CASE OF AN EMERGENCY IF WE ARE UNABLE TO CONTACT PARENTS. I authorize that my child, ______________________________, be released by the First Baptist Church Mother’s Day Out Program to the following individuals: Relationship to Child

Name

Phone Number

For the following questions, please briefly explain “Yes” answers in the space provided. Does your child have any food allergies? Yes

No

_________________________________________

Does your child have any dietary restrictions? Yes No

_________________________________________

Does your child have any other allergies? Yes No

_________________________________________

Does your child have any medical conditions? Yes No

__________________________________________

Child’s Doctor: ______________________________________

Doctor’s Phone #: ____________________

Child’s Dentist: ______________________________________

Dentist’s Phone #: ____________________

I authorize First Baptist Church Mother’s Day Out Program to secure emergency medical treatment for my child.

Parent’s Signature: ________________________________________________ Date: __________________ (Back)

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91 99628 07801. Website : sicasa.sircoficai sircoficai sircoficai.org and www.icai.org. Mail : [email protected] [email protected] [email protected], [email protected]

Offsite activities include events like bowling or laser tag. Small group events may be held in the church, in leaders home, the park, or other public locations. I release NKMB of liability in the event of an accident which may occur during an event.