Childcare Registration Form for Footprints at Mt Dora First United Methodist Church

Childcare Registration Form for Footprints at Mt Dora First United Methodist Church

Please fill out the form with your child's details and pay the registration fee to complete the enrollment. If you have any questions please reach out to the church office 352-383-2005 or email family@mtdorafumc.org
Child’s Full Name

First NameLast Name
Child’s Date of Birth

MonthDayYear
Date
Child’s Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian #1 Full Name

First NameLast Name
Parent/Guardian #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1 Email Address
example@example.com
Parent/Guardian #2 Full Name

First NameLast Name
Parent/Guardian #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Email Address
example@example.com
Emergency Contact Name (other than parents/guardians)

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Persons Authorized to Pick Up Child (List all names and relationship to child)
Physician’s Name

First NameLast Name
Physician’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
List any allergies, medical conditions, or medications
Prefered Hospital
Any Medical Condition we should be aware of
Consent for Emergency Medical Care
Consent to photograph
Parent/Guardian Signature
Should be Empty: