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.
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
I consent to emergency medical care for my child as needed.I do NOT consent to emergency medical care for my child.
I consent to my child’s photo being used for advertising at Footprints at Mount Dora FUMC. Example: flyers, Facebook, instagram, social media, website.I do not consent to my child’s photo being used in any capacity at Footprints at Mount Dora FUMC.
Parent/Guardian Signature*

Footprints Registration and Weekly Fee Payment

Registration Fee

One-time registration fee for Footprints program.

$100.00

Weekly Tuition

Weekly camp tuition for Footprints program. Due on Monday mornings before drop off.

$125.00 Quantity

Total

$0.00

Credit Card

Should be Empty: