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 30-April 3: Currently Enrolled Students
April 6-10: Children with siblings enrolled in St. John Nepomuk Catholic School
April 13-17: Children of registered parishioners of St. John Nepomuk Catholic Church
April 20: 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.
Yes
Child Name*

First NameLast Name
Child Date of Birth*

MonthDayYear
Date
MaleFemale
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)*
YesNo
Please explain
Church & Faith Information
YesNo
YesNo
Media Release
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:
Yes
Yes
Yes
Yes
Yes
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*

Clear
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