Parents Day Out Registration Form

Child's Information
Child's Name *
Child's Name
Child's Date of Birth *
Child's Date of Birth
Session *
Address *
Mother's Information
Mother/Guardian's Name *
Mother/Guardian's Name
Daytime Phone *
Daytime Phone
Cell Phone *
Cell Phone
Father's Information
Father/Guardian's Name *
Father/Guardian's Name
Daytime Phone *
Daytime Phone
Cell Phone *
Cell Phone
In Case of Emergency
If parents are not immediately available contact:
Name, Relation, Phone (list up to 3)
Please list names and ages
Medical/Behavioral Record
Fill out completely
Doctor's Name *
Doctor's Name
Doctor's Phone *
Doctor's Phone
Hospital's Phone *
Hospital's Phone
Permission is granted to meet the needs of my child in case of emergency. This includes transporting and securing medical assistance when necessary. Without such permission, the school assumes no responsibility for emergency medical attention.
Potty Trained *
Does your child nap? *
Please also list anything necessary to help them nap:
Photo Release
Do you consent that this information is correct and you have given it freely and willingly? *
Please type full legal name.