2020-2021 Children's Education at WUMC Registration Form
I am Registering for (Choose 1 or more)
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2020 Summer Program
2020-2021 WUMP School Year (3 by Sept 30th & fully potty-trained)
2020-2021 Kingdoms Kids School Year and/or WUMP extended day (6 months to 5 years)
Number of days per week:
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5 days
4 days
3 days
2 days
1 day
I would like to select random days through Kingdom's Kids (another form will be sent to you to select your days)
Child's Name
Child's Name
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First Name
Last Name
Nickname
Date of Birth
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Month
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Day
Year
Date
Gender
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Male
Female
Birth Certificate Number:
Does your child have any known allergies?
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No
Yes
If you answered "Yes" to the above question, please list allergy, reaction, and treatment
Check any of the following illnesses your child has had
Asthma
Frequent Ear Infections or Ear Tubes
Mumps
Whooping Cough
Bronchitis
Eczema
Pneumonia
Polio
Chicken Pox
Frequent Colds
Croup
Convulsions
Measles
Influenza
Rheumatic Fever
Diphtheria
Tonsillitis
Other
Does your child take any medication on a regular basis? If yes, please list name of medication, dosage and medical condition.
Please comment on any additional medical information/special need the child care provider should be aware of:
Does your child have any health issues or concerns in the areas of speech, vision, motor function, hearing? If yes, explain.
Do you have any concerns about your child's development?
Mother's Information
Mother's Name:
First Name
Last Name
Mother's Home Phone
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Area Code
Phone Number
Mother's Cell Phone
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Area Code
Phone Number
Mother's Email
example@example.com
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Place of Employment and Phone Number
Father's Information
Only complete if different from above
Full Name of Father
First Name
Last Name
Father's Home Phone
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Area Code
Phone Number
Father's Cell Phone
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Area Code
Phone Number
Father's Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Place of Employment and Phone Number
Family and Medical Information
Child's Doctor
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Doctor's Office Phone Number
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Area Code
Phone Number
Insurance Carrier
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Insurance ID #
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Emergency Contact, Relationship and Phone #
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Names and Birthdates of Siblings
Persons authorized to pick up my child (include phone numbers and relationship)
Persons NOT authorized to pick up my child (list custody issues, etc)
Has your child had previous daycare or preschool experience away from home?
Please explain any concerns you may have (i.e fears, nap procedures, special discipline, etc.)
WUMC will notify the parent when the child becomes ill or is injured and the parent will arrange to have the child picked up as soon as possible. Parents are required to inform WUMC the next business day if the child develops any communicable disease.
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Agree
By clicking "Agree", you give permission for WUMC employees to apply as needed...diaper rash cream, band aids, 1st aid ointment.
Agree
Disagree
Do you have a special talent or skill that you would like to share with us?
We like to take photos of the children playing and doing activities . We occasionally use the pictures in newsletters, outreach brochures, the WUMC website, and social Media. Children's names and/or ages are not used.
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I hereby grant my permission for photos to be used
I DO NOT grant permission for photos to be used
In the need for evacuation, please hold my child until the following person arrives
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Is there anything else you would like us to know about your child?
My child's Birth Certificate and Immunization Records must be on file before my child can enroll
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Agree
Disagree
By clicking "agree", you authorize and give permission for your child to be transported to a hospital for evaluation and emergency medical or surgical treatment, including any necessary X-ray examination or diagnostic tests, or administration of medication. In consideration of the arrangements set forth herein, you do on behalf of yourself, your child, and your respective heirs, successors, assigns, and next of kin, release, waive, hold harmless, defend and covenant not to sue, Warrenton United Methodist Church and each of their respective departments, directors, administrators, teachers, officers, agents, representative, volunteers, and employees from any and all actions, claims, demands, or liabilities, including without limitation, those for personal injuries or property damage, that you and/or your child may suffer due to illness or injury suffered by your child as a result of this agreement, including medical treatment and any consequences that may arise as the result of this treatment, to the fullest extent permitted by law. You accept full responsibility for any medical or hospital bills associated with the care of your child.
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Agree
Disagree
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