Crosby Church Mother's Day Out Enrollment 2022 Summer and 2022-2023 School Year

Child's Name *

First Name Last Name

Birthdate *

Month/Day/Year

*

Male Female

T-shirt size *

Session *

Summer 2022 School Year 2022-2023

Days for 2022-2023 School Year *

2 days a week 3 days a week 4 days a week (by using Crosby and Huffman campus) 5 days a week (by using Crosby and Huffman campus)

Campus *

Huffman (not available for summer) Crosby Both

Is Your Child Potty-trained *

Parent's 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

Father's Name

First Name Last Name

Father's Driver's License

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Father's Email

example@example.com

Home Phone Number

Area Code Phone Number

Mobile Number

Area Code Phone Number

Work Number

Area Code Phone Number

Father's Occupation

Father's Employer

Mother's Name *

First Name Last Name

Mother's Driver License *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Mother's Email *

example@example.com

Home Phone Number

Area Code Phone Number

Mobile Number *

Area Code Phone Number

Work Number

Area Code Phone Number

Mother's Occupation *

Mother's Employer *

Family religious preference *

Where is Church Membership? *

How did you find out about our program? *

List at least one local person who will be available to assume responsibility for your child in an emergency if parents cannot be reached.

Emergency contact *

First Name Last Name

Relationship to Child *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Driver's License

Occupation

Employer

Home Phone Number

Area Code Phone Number

Mobile Number

Area Code Phone Number

Work Number

Area Code Phone Number

I authorize that my child be released by Little Friends MDO Pre-K of Crosby Church to the following persons, in addition to those already listed if I am unable to pick them up.

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Relationship to Child

Home Phone Number

Area Code Phone Number

Mobile Phone Number

Area Code Phone Number

Work Phone Number

Area Code Phone Number

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Relationship to Child

Home Phone Number

Area Code Phone Number

Mobile Phone Number

Area Code Phone Number

Work Phone Number

Area Code Phone Number

In an effort to be sensitive, responsive teachers and meet your child's unique needs, please complete the following information. Thank you for giving us the opportunity to teach your child.

List all allergies *

What is your child's favorite way to be held, touched, and talked to ? *

What is your child's favorite activity? *

Is your child... *

Very active More laid back

How does your child react to new situations or meeting someone new? *

How is your child used to eating and what would you like us to know about his/her eating habits? *

How does your child react to a change in his/her routine? *

How does your child show anger, sadness, or excitement? *

How does your child react to transitions - home to center, play to a meal, play to bed, etc.? *

Is your child persistent when she/he has a hard time doing something? *

Yes No

How does your child react toward other children? *

Does your child have other siblings? If so what are their names and ages? *

Does he or she enjoy: *

being around other children being alone

How does your child usually like to nap? (What do they sleep with, like to be patted or rocked, etc.,) *

From time to time Crosby Church MDO Pre-K will photograph daily events. Some of these images will shared with parents and may be shared on the church's Facebook page or website. By signing below, you are granting us permission to publish your child's photo.

Signature

Clear

Crosby Church Mother's Day Out program will be able to send out text alerts to our families in our program. This will be a way of reminding about upcoming events, picture day, etc. If you would like to receive these, please indicate that below.

I want to receive text alerts from Mother's Day Out *

Yes No

You will need to pay the non-refundable registration fee below for the program or programs of your choosing to be registered. We will contact you with start dates, open house times, etc. You will also need to turn into us

1.) A notarized medical release form. (Found on our website)

2.)We will need a recent picture of your child

3.) A signed parent agreement that you have read our policies and procedures and agree to them. (Found on our website)

4.) Copy of your medical insurance card

5.) Updated shot record

6.) Copy of your driver's license

Those items can be scanned and emailed to MDO@crosbychurch.com or turned into the office

Crosby Church Mother's Day Out Enrollment for Summer and 2022-2023 School Year