MDO Enrollment Form

Please fill out as completely as possible:

Comments or questions are welcome.

* indicates required field

Name:*

Email:*

Child's Name:*

Home Address (street, city, state, ZIP):*

Best Phone Number:*

Child's Birthdate:*

Days Needed for Care:*

TUE
WED
THU

Mother's Information (include employment data, telephone numbers and email addresses):

Father's Information (include employment data, telephone numbers and email addresses):

Child's Physician Information (include name of doctor/clinic, phone number and hospital preference):*

Health Issues, Food Sensitivities and Allergies:*

First Emergency Contact (include relationship and phone number):*

Second Emergency Contact (include relationship and phone number):

Third Emergency Contact (include relationship and phone number):

The following people (up to 4 names) are authorized to pick up my child (in addition to parents):

By entering my initials in the following box, if a medical emergency occurs and I cannot be reached, I authorize the persons in charge of the CUMC Mother’s Day Out to take my child to the nearest emergency room and/or call my physician. I assume all financial responsibility for any accidents occurring while at Mother’s Day Out or on the premises of Choctaw United Methodist Church.*

Your email address will be utilized by the Mother’s Day Out to send out the monthly newsletter and reminders about upcoming events. Please include the most appropriate email address for that purpose.