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PLEASANT GROVE BAPTIST CHURCH
MOTHERS’ MORNING OUT
Registration Form

CHILD’S NAME: ________________________BIRTHDATE: ______________________

ADDRESS:   ____________________________CITY/STATE/ZIP:___________________

** DENOTES MANDATORY NUMBERS FOR EMERGENCY CONTACTS   

**HOME PHONE #: ____________________**CELL #(MOTHER)_________________

**CELL#(FATHER)_____________________**PAGER#___________________________

AGE AS OF OCT. 16, 2008: ___________

FATHER’ S NAME: ____________________OCCUPATION: _______________________

BUSINESS ADDRESS: _____________________________PHONE: _________________

MOTHER’S NAME: ____________________OCCUPATION: _______________________

BUSINESS ADDRESS: ____________________________PHONE: __________________

LIST BROTHERS AND/OR SISTERS AND AGE: _______________________________

IN CASE OF EMERGENCY WHEN NEITHER PARENT IS AVAILABLE, WE SHOULD CONTACT:

NAME: _____________________________________PHONE: ________________________

RELATIONSHIP TO CHILD: _________________________________________________

CHILD’S PHYSICIAN: ____________________________PHONE: ___________________

CHURCH YOU ATTEND: _____________________________________________________

IF NO MEMBERSHIP, GIVE CHURCH PREFERENCE: ________________________

ANY KNOWN ALLERGIES (FOOD, ETC.)?__________________________________

DOES YOUR CHILD HAVE ANY DISABILITIES, ANY MEDICAL CONDITIONS, OR ANY ADDITIONAL INFORMATION HIS/HER TEACHER SHOULD BE AWARE OF?

A COPY OF YOUR CHILD’S IMMUNIZATION RECORDS WILL BE REQUIRED UPON ENTERING MMO

CHILD’S NAME: ___________________________________________

PLEASE INDICATE WHICH DAYS YOU WOULD LIKE TO ENROLL YOUR CHILD:

_______5 DAYS (MONDAY – FRIDAY)

_______3 DAYS (MONDAY, WEDNESDAY, FRIDAY)

_______2 DAYS (TUESDAY, THURSDAY)

A NON-REFUNDABLE REGISTRATION FEE OF $85.00 MUST ACCOMPANY THIS APPLICATION (NO REFUND EXCEPT IF SPACE IS UNAVAILABLE).  SPACE AVAILABILITY IS ON A FIRST COME, FIRST SERVE BASIS.

      PLEASE MAKE CHECKS PAYABLE TO:

PLEASANT GROVE BAPTIST CHURCH MMO

PARENT’S SIGNATURE: _________________DATE: _____________