St. John Nepomuk Mother's Day Out Registration Form

St. John Nepomuk Mother's Day Out Registration Form

Completing this form does not guarantee your child a spot in the program.
Priority Submission dates

March 23-29: Currently Enrolled Students
March 30-April 5: Children with siblings enrolled in St. John Nepomuk Catholic School
April 6-12: Children of registered parishioners of St. John Nepomuk Catholic Church
April 13: Open to the public

Submissions will be reviewed on submission dates based on priority. If you submit a registration form prior to your priority submission date, it will not be reviewed.
I read and understand the priority submission dates*

Yes
Child Name*

First NameLast Name
Child Date of Birth*

MonthDayYear
Date
Child Gender*

MaleFemale
Is your child potty trained?*

YesNo
Child Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Parent/Guardian*

First NameLast Name
Relationship to Child*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address (If different from child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address (If different from child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information

Other than Parent/Guardian
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorization Pick-up List
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Medical Information
Physician Name*
Physician Phone*
Please enter a valid phone number.Format: (000) 000-0000.
List any Allergies (If none, type none)*
List any Medical Conditions (If none, type none)*
Does your child take medication regularly?*

YesNo
Please explain
Church & Faith Information
Do you have a sibling enrolled in St. John Nepomuk Catholic School?*

YesNo
Are you a registered member at St. John Nepomuk Catholic Church?*

YesNo
Media Release
Please select one*

I give permission for my child’s photo to be used for internal purposes, such as classroom displays, parish newsletters, or end-of-year slideshows (no names will be shared publicly).I do not give permission for my child’s photo to be used.
Parent Handbook Agreement
2025 - 2026 St. John Nepomuk’s Mother’s Day Out Program.

We are grateful for the opportunity to care for and support your child in a loving, Christ-centered environment. This agreement acknowledges that you have received, read, and agree to follow the guidelines outlined in the St. John Nepomuk’s Mother’s Day Out Parent Handbook. A printable version will be available for pick-up at Open House.
Please read and acknowedge you agree with each statement:
I have received and read the Mother’s Day Out Parent Handbook.*

Yes
I have received the payment calendar and understand payment due dates.*

Yes
I understand and agree to abide by the policies and procedures outlined, including those regarding health and safety, tuition, discipline, arrival and dismissal, and emergency protocols.*

Yes
I understand that participation in the Mother’s Day Out program is a partnership between the parish staff and my family, and I agree to communicate openly and respectfully with the staff.*

Yes
I agree to provide all required forms (including medical and emergency information) and keep them updated throughout the year.*

Yes
I agree to support the Catholic values taught in the classroom and understand that religious activities and prayer are integral parts of the program.*

Yes
By signing below, I confirm that I have read and understand the information in the Parent Handbook and agree to comply with the policies and expectations of the St. John Nepomuk Mother’s Day Out Program.
Signature*
Should be Empty:

St. John Nepomuk Mother's Day Out Registration Form

Parent/Guardian Information

Emergency Contact Information

Authorization Pick-up List

Medical Information

Church & Faith Information

Media Release

Parent Handbook Agreement