2021-22 MDO REGISTRATION FORM

2021-22 Registration Form

(a separate form must be submitted for each child)
Registration information

Once this application is received, you will be contacted directly via the email address provided to confirm your child's placement. To secure placement, a *nonrefundable* registration fee of $150 will be collected for each child. Spots will be filled based on the time and date of receipt of this registration fee, which can be paid via check or PayPal.
Class times and tuition

Our classes meet on Mondays and Wednesdays, 9am-2:30pm. Tuition is due by the 3rd of each month, September-May. Base tuition for children 12 months-23 months (as of September 1) is $200/mo; tuition for children 24 months and above (as of September 1) is $180/mo. There is a 10% sibling discount for each additional child. (For example, if you are enrolling a one year old, a three year old, and a four year old, you would be invoiced at $200 for the first child, with a discounted rate of $162 for the two others, for a monthly total of $524.)
Early Bird and Late Day

You may sign up for our optional Early Bird (7:45-9am) and/or Late Day (2:30-3:45pm) sessions for an additional fee (sibling discount does not apply). Please see below.
Indicate below if you would like to utilize one or both of these optional services.

Early Bird, $40/month Late Day, $40/month BOTH Early Bird AND Late Day, $60/month
CHILD’S BASIC INFORMATION
Child's Full Name: *
Date of Birth: *

Month Day Year
Date
Preferred Name/Nickname:
Gender: *

Female Male
Please upload a recent photo of your child for classroom use. *
Audio/Visual Information: *

I understand that my child may be photographed or recorded at Foundation Kids MDO during normal school hours, field trips, or special activities. I understand that these photographs or videos may be posted in school newsletters/bulletin boards, or posted on our website, social media, or other publication for publicity or information purposes. I understand that, if consent is now given below, I have the right to rescind that consent in writing at any time.
Audio/Visual Consent *

Yes, I confirm that I have read and understand the above and give permission for my child’s image to be used in the manner described. No, I do not wish to have my child’s likeness used in the manner described.
Child lives with: *
Parents' Marital Status:
If separated, who has legal custody?
May the non-custodial parent pick up the child?

Yes No (court documentation is required)
CHILD’S HEALTH INFORMATION
Does your child have any known allergies? *

Yes No
If yes, please list the allergen(s) and describe how your child reacts to exposure.
How are these allergies typically treated?
Does your child take daily medication that needs to be administered during the school day? *

Yes No
If yes, please list them below.
Please indicate below which general use medication we may use as necessary.

Diaper cream Insect repellant Cortisone/anti-itch cream Antibiotic ointment Sunscreen
Are there any other medical issues or special needs (emotional/sensory/physical) we should know about? *
We will make every effort to accommodate your child but some needs may be beyond our current capabilities. We highly recommend you discuss potential needs with our Director before registering.
Emergency Medical Care: In the event I cannot be reached to make arrangements for emergency medical attention, I authorize the staff of Foundation Church and Foundation Kids Mother's Day Out to seek assistance from the following physician and/or have my child transported for emergency care to the following emergency medical care facility:
Physician's Name:
Clinic:
Phone #:
Address:
Emergency Care Facility Name:
Immunization Record *

I am attaching a copy of my child’s current immunization record. I am excluding my child from immunization requirements for reasons of conscience. I have attached an official notarized affidavit issued by the Department of State Health Services. I understand this affidavit is valid for two years. My child cannot receive immunizations for medical reasons. I have attached a statement of exclusion from my child’s physician. My child is a returning student and you have his/her current immunization documentation on file. If I previously submitted a notarized affidavit of exclusion, I understand a new one must be submitted every two years.
Please upload your child's immunization documentation as indicated above.
GUARDIAN #1 INFORMATION
Guardian's Name: *
Relationship to Child: *
Address: *
Cell Phone #: *
Email Address: *
Driver's License #:
GUARDIAN #2 INFORMATION
Guardian's Name:
Relationship to Child:
Address:
Cell Phone #:
Email Address:
Driver's License #:
EMERGENCY CONTACT #1

List a person who will assume responsibility if guardian(s) cannot be reached.
Emergency Contact Name: *
Relationship to Child: *
Cell Phone #: *
Driver's License #:
EMERGENCY CONTACT #2

List a person who will assume responsibility if guardian(s) cannot be reached.
Emergency Contact Name:
Relationship to Child:
Cell Phone #:
Driver's License #:
Phone #:
Address:
Confirmation of Intended Registration

I have reviewed the above for any errors and certify all entries are correct to the best of knowledge.
By completing this registration form: *

I confirm that I have read and will abide by all the policies and procedures as outlined in the Parent Handbook, which is available for review on the MDO website. I understand that I will receive a hard copy at Meet the Teacher Night in the fall. I give consent for the staff of Foundation Church/Foundation Kids Mother's Day Out to secure any and all necessary emergency medical care for my child at my own expense. I understand that classes may be divided or combined based on enrollment. I understand that, if offered placement, my registration fee is *nonrefundable* and I will notify the MDO office as soon as possible if my status changes so my child's spot can be released to those on the waiting list.
Parent/Guardian Electronic Signature *

Clear
Today's Date *

Month Day Year
Should be Empty:

Registration information

Class times and tuition

Early Bird and Late Day

CHILD’S BASIC INFORMATION

CHILD’S HEALTH INFORMATION

GUARDIAN #1 INFORMATION

GUARDIAN #2 INFORMATION

EMERGENCY CONTACT #1

EMERGENCY CONTACT #2

Confirmation of Intended Registration