2024/2025 MDO Registration Form

MDO Registration Form

2024-2025
*This facility is not required to be licensed by the state as a child care agency.
Eligibility shall be granted without discrimination in regard to sex, color, or political belief on a first come, first serve basis. Any child ages 6 weeks to 5 years (before entering Kindergarten) is eligible, provided the program can meet the needs of the child and if there is space available as determined by the director.

Please fill out one form per child. If you are registering siblings, each child will need their own application.

If your child is granted admission, you will recieve a letter in the mail by the end of July.

There is an annual $25 supply fee due with each admission. This fee can be paid in person, mailed to the church, paid on line at the church website, or paid at open house.

**AGES 3 AND UP MUST BE POTTY TRAINED AT THE START OF SCHOOL**
Are you a member of First Baptist Church Greeneville?*

YesNo
Was your child enrolled in MDO during the 2022/2023 school year?*

YesNo
Do you have any other children *CURRENTLY* enrolled in MDO?*

YesNo
What is the name of the sibling currently enrolled in MDO?
Child's Name*

First NameLast Name
Child's Gender*

MaleFemale
Child's Birthday*

MonthDayYear
Date
Mother's Name*

First NameLast Name
Mother's Phone Number*

Area CodePhone Number
Do you receive texts this number?*

YesNo
Mother's Email Address*
Mother's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Business Phone

Area CodePhone Number
Father's Name*

First NameLast Name
Father's Phone Number

Area CodePhone Number
Do you receive texts this number?

YesNo
Father's Employer
Father's Email Address
Address (If different than Mother's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status *
Is your child fully potty trained?*
(Using the toilet for both #1 & #2 with little to no accidents)
Do you give us permission to take photographs of your child?*

YesNo
Church Home
Family Insurance Company*
Insurance Policy Number*
Family Physician*
Physician Office Phone Number*

Area CodePhone Number
In Case of Emergency Notify: (AFTER PARENTS!)
Name: *
Relationship*
Phone Number*

Area CodePhone Number
Name: *
Relationship*
Phone Number*

Area CodePhone Number
Name: *
Relationship*
Phone Number*

Area CodePhone Number
Medical Information
Food Allergies (Please list all)*
Insect Sting/Bite Allergies (Please list all)*
Other Allergies (Please list all)*
Previous Operations or Serious Illnesses*
Current Medications: (Please list all)*
Are immunizations up to date?*
If immunizations are not up to date, please explain.
Has your child been diagnosed with a developmental or learning disability you'd like to make our program aware of? If yes, please explain.
Miscellaneous
What is your child shirt size?*
Comments/Questions/Concerns
DateTime
Should be Empty:

MDO Registration Form

In Case of Emergency Notify: (AFTER PARENTS!)

Medical Information

Miscellaneous