MDO Registration

First Baptist Church Mother's Day out and Preschool Enrollment Form

311 North Pine Street Vivian LA 71082

(318)455-8939 or (318) 375-3245
Child's Name
Sex
Ethnicity
Address

Address

Street Address Line 2

City, State, State / Province

Zip
Birth Date

MonthDayYear
Date
Home Phone #
Format: (000) 000-0000.
Admission Date

MonthDayYear
Date
Class
PARENT INFORMATION:
Marital Status
Number of children
Ages
Religious Affiliation
Church
Child lives with
Father's Name
Address
Phone #
Format: (000) 000-0000.
Employment
Work Phone #
Format: (000) 000-0000.
Mother's Name
Address
Phone #
Format: (000) 000-0000.
Employment
Work Phone #
Format: (000) 000-0000.
PERSON TO CALL IN EMERGENCY WHEN PARENT CANNOT BE REACHED:
1- Name
Relationship
Address
Phone #
Format: (000) 000-0000.
2- Name
Relationship
Address
Phone #
Format: (000) 000-0000.
Describe child's past illnesses and/or physical defects:
Describe child's habits
Likes
Dislikes
Favorite Hobby
Ability to play with other children:
Toilet Training
Person(s) to whom child may be released
$100 Registration Fee (Non-Refundable) and $140 per month for 1 child$100 Registration Fee (Non-Refundable) and $260 per month for 2 children ($130/child)$100 Registration Fee (Non-Refunable) and $360 per month for 3 children ($120/child)
CODE WORD
Emergency Medical Information:
Doctor
Address
Phone #
Format: (000) 000-0000.
Dentist
Address
Phone #
Format: (000) 000-0000.
Insurance Co.
ID#
Hospital
Please list any allergies or special medical information the school may need to know about:
PARENTS SIGNATURE

Clear
DATE

MonthDayYear
Date
Should be Empty:

PARENT INFORMATION:

PERSON TO CALL IN EMERGENCY WHEN PARENT CANNOT BE REACHED: