Parent's Day Out - Enrollment Form

Which session would you like to enroll in?

Current Session Summer Fall

Child's Name

Gender

Date of Birth

Address

Mother's Name

Mother's Email

This address will receive a confirmation email

Work or Cell Phone

Father's Name

Father's Email

This address will receive a confirmation email

Work or Cell Phone

Please list 2 alternate contacts in case you cannot be reached in an emergency:

Name

Relationship

Phone

Name

Relationship

Phone

Helpful Hints for Teachers: Does your child prefer to use his right or left hand when coloring, etc?

List any fears, worries, or habits:

Medical Information

Child's Name

Please list any medication or medical treatment your child is currently on; also list any health problems, asthma, or allergies (food, drug, animal, hay fever, etc) that your child has:

List any specific physical, social, or emotional conditions that might have an affect on your child while at school:

Doctor's Name

Doctors Phone

Doctors Address

Hospital Preference

Insurance Company Name:

Policy Number

By typing your name below, you are granting permission for Christ’s Church of Yukon Parent’s Day Out to meet the needs of your child in case of an emergency. You are also stating your understanding that Christ’s Church of Yukon is not liable for any doctor or hospital charges that may occur while your child is under their care.

Parent's Name/Signature

Date:

Description

Please fill out this form and click submit.

Parent's Day Out - Enrollment Form

Description

Please Fix the Following