THE LITTLE MORNING CO.
MOTHER'S DAY OUT
little mornings. big adventures.
PROGRAM SCHEDULE
Monday 8:30-11:00 AM | Wednesday 8:30-11:30 AM | Friday 8:00 AM-12:00 PM
SESSION RATES
Monday $25 | Wednesday $30 | Friday $40 | Maximum 2 booked children per session
Please complete one registration form for each child. Registration information is kept on file for safety, emergency contact, authorized pickup, and program communication.
CHILD INFORMATION
Child's full name
First Name
Last Name
Preferred name / nickname
First Name
Last Name
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Home address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary language
Pronouns (optional)
Days you are interested in booking:
Monday
Wednesday
Friday
PARENT / GUARDIAN INFORMATION
Parent / guardian 1 name
First Name
Last Name
Relationship to child
Phone
Format: (000) 000-0000.
Email
example@example.com
Parent / guardian 2 name
First Name
Last Name
Relationship to child
Phone
Format: (000) 000-0000.
Email
example@example.com
Home address (if different from child's)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred contact method:
Call
Text
Email
EMERGENCY CONTACTS
Please list at least one person other than the parent/guardian who may be contacted in an emergency.
Emergency contact 1
First Name
Last Name
Relationship
Phone
Format: (000) 000-0000.
Alternate phone
Format: (000) 000-0000.
Emergency contact 2
First Name
Last Name
Relationship
Phone
Format: (000) 000-0000.
Alternate phone
Format: (000) 000-0000.
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AUTHORIZED PICKUP
Only a parent/guardian or an adult listed below may pick up the child unless written permission is provided. Photo identification may be requested.
Authorized person 1
First Name
Last Name
Relationship
Phone
Format: (000) 000-0000.
Authorized person 2
First Name
Last Name
Relationship
Phone
Format: (000) 000-0000.
Anyone who is NOT permitted to pick up this child
First Name
Last Name
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THE LITTLE MORNING CO.
Little Mornings. Big Adventures.
HEALTH, ALLERGIES & CARE INFORMATION
Child's pediatrician
First Name
Last Name
Pediatrician phone
Format: (000) 000-0000.
Preferred hospital
Insurance provider (optional)
Allergies (food, medication, environmental)
Medical conditions / diagnoses we should know about
Current medications
Dietary restrictions / feeding concerns
Toileting / diapering information
Sensory, developmental, behavioral, or communication needs
Comfort items, calming strategies, or other helpful information
Does your child have an EpiPen, inhaler, rescue medication, or other emergency medical item?
Yes
No
If yes, please explain
CHILD PREFERENCES & ROUTINE
What does your child enjoy playing with / doing?
Anything your child dislikes, fears, or may find upsetting?
How does your child typically communicate needs? Anything else that will help us make your child's morning successful?
EMERGENCY MEDICAL AUTHORIZATION
If I cannot be reached in an emergency, I authorize The Little Morning Co. to obtain emergency medical care for my child as reasonably necessary. I understand that every reasonable effort will be made to contact me and/or the emergency contacts listed on this form. I accept responsibility for expenses associated with emergency medical care.
Parent / guardian initials
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PHOTO & MEDIA PERMISSION
Please select one:
Permission Selection
YES - I give permission for photos of my child to be used on The Little Morning Co. social media / marketing.
NO - Please do not use identifiable photos of my child.
Photos may still be taken for private parent communication or documentation only when appropriate and permitted by the family.
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PARENT AGREEMENT
Agreement Terms
*
I certify that the information on this form is accurate and will notify The Little Morning Co. of changes.
I understand that a booked session is for the specific date/time reserved and that pickup is required by the session end time.
I agree to follow the program's illness, cancellation, payment, pickup, safety, and behavior policies provided separately.
I understand that enrollment/registration does not guarantee availability for every requested session because space is limited to 2 booked children per session.
I will provide accurate allergy, medical, emergency, and authorized-pickup information before my child attends.
Parent / guardian printed name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent / guardian signature
*
FOR PROGRAM USE
Registration received:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
First session:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Notes:
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