Form
St. Luke's Parent's Day Out Registration
Child's Name
*
First Name
Last Name
Child is
*
Boy
Girl
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child lives with:
Please Select
Both Parents
Mother Only
Father Only
Other
Siblings and their ages:
List any special problems or needs your child may have, including allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, medication prescribed for long-term continuous use. Food allergies require an emergency plan signed by your doctor on file in the office. If none, please write, "NONE."
*
My Child will be attending (Check all that apply)
*
All Day Wednesday/Friday
All Day Tuesday/Thursday
Summer PDO Wednesday/Friday
Afternoon PDO for Enrolled Preschool
Morning Only Wednesday/Friday
Morning Only Tuesday/Thursday
I understand and comply with the financial policies of St. Luke's PDO.
*
Please Select
Yes
No
I grant permission for my child to be transported by the St. Luke's staff for emergency care.
*
Please Select
Yes
No
I acknowledge receipt of "St. Luke's Operational Policies" including those for discipline and guidance. (See Attached)
*
Please Select
Yes
No
Operational Policies
I grant permission for my child to use all the play equipment & participate in all of the activities of school.
*
Please Select
Yes
No
I grant permission for use of diaper rash ointment
*
Please Select
Yes
No
Does Not Apply
I grant permission for my child to be included in pictures and videos connected with the school and church programs.
*
Please Select
Yes
No
I grant permission for use of sunscreen, if outside for extended period.
*
Please Select
Yes
No
I grant permission for photos which include my child to be posted on the school Facebook page and/or the church website. (No child will be identified by name.)
*
Please Select
Yes
No
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Father or Guardian
*
First Name
Last Name
Father's/Guardian Cell Phone
*
Please enter a valid phone number.
Mother or Guardian
*
First Name
Last Name
Mother's/Guardian Cell Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Physician's Name
*
First Name
Last Name
Physician's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician's Phone Number
*
Please enter a valid phone number.
Name of Preferred Hospital
*
Hospital's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hospital's Phone Number
*
Please enter a valid phone number.
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Signature
Emergency Contact (other than mother/father)
*
First Name
Last Name
Emergency Contact's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact's Phone Number
*
Please enter a valid phone number.
Relationship to Child
*
Emergency Contact (other than mother/father)
*
First Name
Last Name
Emergency Contact's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact's Phone Number
*
Please enter a valid phone number.
Relationship to Child
*
My emergency contacts are also authorized to pick up my child.
*
Please Select
Yes
No
List any other authorized pick-up including name, relationship to child and phone number.
Check if you do NOT authorize anyone to pick up my child
I do NOT authorize anyone to pick up my child.
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