Registration Form
Summer 2024
Child's Information
Full Name
*
Name to be called
Date of Birth
*
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child lives with
*
Both Parents
Dad
Mom
Other
If Other, please list name and relationship.
Medical or Developmental Issues (allergies, hearing, eyesight, behavior, attention deficit, etc.) (write N/A if none)
*
Is your child's immunizations up to date? (A copy of your child's immunization records is required before the first day of school)
*
Yes
No
Mother's Information
Name
*
Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer & Occupation
Work Phone
Please enter a valid phone number.
Cell Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Father's Information
Name
*
Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer & Occupation
Work Phone
Please enter a valid phone number.
Cell Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Authorizations & Releases
Emergency Contact Info: Please list contacts that can be called in case of an emergency or illness and parents/guardians can't be reached. For example John Doe/Grandparent/111-222-333
*
List up to 3 contacts other than parents (Name, Relationship to Child and Phone Number)
Child Pick up Authorization: Please list up to three individuals who you give permission to pick your child up from Shining Stars. For example John Doe/Grandparent/111-222-3333
*
List up to 3 contacts other than parents (Name, Relationship to Child and Phone Number)
Is there a court order preventing anyone from picking up your child? (If a court order exists, Shining Stars Mother's Day Out will need to be provided with a copy to keep on file.)
Yes
No
Medical Information
Child's Physician
*
Name and Phone Number
Child's Dentist
*
Name and Phone Number
Primary Insurance
Provider
Contract Number
Group Number
State / Province
Postal /Zip Code
I am the parent with legal custody, guardian or managing conservator of the above mentioned minor child. I hereby give permission for my minor child to participate in all the activities of Shining Stars Preschool & Mother's Day Out. This authorization is for the purpose of securing benefits for the health and welfare for my minor child and expressly includes the authority to sign releases for physicians and hospitals that may render medical care and services. I authorize all medical and surgical treatment, x-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency. I release Morningstar Methodist Church and Shining Stars Preschool & Mother's Day Out and individuals from liability in case of an accident during all activities related to Shining Stars Preschool & Mother's Day Out, as long as normal safety procedures have been taken.
*
Name
*
First Name
Last Name
Signature Date
*
-
Month
-
Day
Year
Important Program Information
- REGISTRATION FEE: $25.00. The registration must be paid to hold your child's spot for summer camp. Registration fees are non-refundable. -SUPPLY FEE: $40.00 -TUITION: $200.00 -FAMILY TUITION DISCOUNT: 15% off the the youngest siblings tuition. -LATE FEE: Tuition is due on the 1st of each month with a 3 day grace period. If the tuition payment is turned in after the allotted time given a $35.00 late fee will be charged -RETURN CHECK FEE: A late fee will be charged for returned checks. -IMMUNIZATION FORMS: Blue forms are required by the first day of camp.
Submit
Submit
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