Enrollment Forms

PDO Enrollment Forms
Child's Name *

First Name Last Name
Birth Date *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mother/Guardian's Name: *

First Name Last Name
Phone Number: *

Area Code Phone Number
Father/Guardian's Name: *

First Name Last Name
Phone Number: *

Area Code Phone Number
Doctor or Clinic Name: *
Phone Number: *

Area Code Phone Number

EMERGENCY CONTACTS

Please provide the following information for people who may pick up your child(ren).
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to child: *
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to child: *
Optional 3rd Person Name:

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to child:

DISCLOSURE OF MEDICAL CONDITIONS

PDO AT FELLOWSHIP UMC
It is imperative that we be informed of any medical conditions or specials needs in order to safely and properly care for your child. Failure to report information that is vital to the care of your child could result in the loss of your child's slot in the PDO program. This information will be kept confidential and will only be shared with staff that is directly responsible for your child. In the event of a medical emergency, we reserve the right to share this information with emergency medical personnel. Please note that PDO CANNOT distribute medication and in some cases, PDO may be unable to care for children with special medical needs.
Child's Name: *

First Name Last Name Suffix
Does your child have any ongoing medical conditions such as ASTHMA, SEIZURES, SKIN CONDITIONS, DIABETES, etc.? *

Yes No
If YES, please list below:
Does your child have any allergies to FOOD, MEDICINE, INSECT BITES, etc. ? *

Yes No
If YES, please list below:
Parent/Guardian Signature *

Clear
For Office Use Only:
PDO Director Signature:
Date

Month Day Year
Date
Teacher's Signature:
Date

Month Day Year
Date

PDO SCHOOL FINANCIAL CONTRACT WITH PARENTS

FELLOWSHIP UMC PARENT'S DAY OUT
Child's Name: *

First Name Last Name Suffix
Please initial below to show your agreement to each statement:
I have enrolled my child in PDO. I understand that I am responsible for paying a non-refundable registration fee of $100 in addition to the monthly tuition cost out lined below *
Monthly tuition of $125 is due the first school day of each month (or you may pay quarterly or annually). Subsequent children will receive a $10 discount per month for tuition. *
I understand that there are no partial month payments. If my child attends PDO at any time during the month, full tuition is due for that month. *
I understand that if my tuition fee is not received by the first school day of the month, I will be charged a $15 (per child) late fee. After the fourth day, I will be assessed a $25 (per child) late fee. *
I understand that PDO operates from 9:00 am to 2:15 pm and that I will pick up my child no later than 2:15 pm. After 2:30 pm, I will be charged a $10 fee for the first 15 minutes and $1.00 per minute fee if my child is not picked up *
I understand that no credit will be given for absences due to vacations, illness, and holidays. I will also give a 30-day written notice if I plan to withdraw my child from the program to avoid an early termination fee. *
I understand that if my check is returned, I need to pay $30 for returned fees, plus any applicable late fees listed above. *
I understand that during December and May, no personal checks will be accepted. *
I realize that PDO program reserves the right to adjust the PDO schedule as needed. *
I have and agree to abide by the policies and procedures mentioned in the PDO Handbook. I understand that failure to abide by those regulations can result in immediate withdrawal of my child(ren) from the PDO program. *
Date *

Month Day Year
Date
Parent/Guardian Signature: *

Clear
PDO Director Signature:
Date

Month Day Year

PHOTOGRAPH RELEASE FORM

FELLOWSHIP UMC PARENT'S DAY OUT
I DO or DO NOT grant permission to Fellowship UMC Parent's Day Out program to use my child's photograph for the purpose of promoting and sharing the activities and daily routines of the PDO program on our church/PDO website and Facebook page www.fellowshipumc.com and www.facebook.com/FellowshipPDO *

I DO grant permission I DO NOT grant permission
Parent/Guardian Signature: *

Clear
Date *

Month Day Year
Date
Should be Empty:

PDO Enrollment Forms

EMERGENCY CONTACTS

DISCLOSURE OF MEDICAL CONDITIONS

For Office Use Only:

PDO SCHOOL FINANCIAL CONTRACT WITH PARENTS

Please initial below to show your agreement to each statement:

PHOTOGRAPH RELEASE FORM