Form
St. Luke's Parent's Day Out Registration
Child's Name
*
First Name
Last Name
Parent's Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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 will comply with the financial policies of St. Luke's PDO
*
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 use of sunscreen, if outside for extended period.
*
Please Select
Yes
No
I give consent for the facility to secure any and all necessary emergency medical care for my child.
*
Please Select
Yes
No
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