LilyRoze Little Starz MDO Registration Form

Information of Child
Name

First NameLast Name
Birth Date

MonthDayYear
Date
M.I.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

FemaleMale
Hours of child care required ( 8:30 am to 2:30 pm)

Full dayOther
Days of the week required

TuesdayWednesdayThursdayFriday Mini-Camp
Information of Parent
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Place of Work
Emergency Contact 1
In the event of an emergency, please contact:
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Place of Work
Other people authorized to pick up child from school
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Place of Work
Medical Information
Doctor's Name

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dentist's Name

First NameLast Name
Dentist's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred hospital
Insurance/health coverage
I authorize LilyRoze Performing Arts Academy staff to obtain emergency medical care for my child if I cannot be reached and urgent care is required. I understand I am responsible for any related medical expenses.

YesNo
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
I understand that participation in the Mother’s Day Out program carries some inherent risk. I release and hold harmless LilyRoze Performing Arts Academy, its owners, staff, and representatives from any liability, injury, loss, or claim that may arise from my child’s participation, except in cases of gross negligence.

YESNO
Do you grant permission for LilyRoze Performing Arts Academy to use photos and videos of your child for classroom documentation, marketing, website, or social media?

YESNO
I certify that all information provided is accurate. I acknowledge and agree to all terms and conditions of enrollment in the LilyRoze Mother’s Day Out Program
Should be Empty:

Information of Child

Information of Parent

Medical Information