MDO Registration Fall 2020 / Spring 2021

Enrolling now for Fall 2021/Spring 2022

Thank you for your interest in our program.

FTBC Mother's Day Out Program is on Tuesdays and Thursdays from 9:00 a.m. - 2:00 p.m.

Today's Date

Child's Information

Child's Name

Prefers to be called

Age (as of Sept 2021)

Birthdate

Gender

Male Female

Address

This address will receive a confirmation email

Cell Phone

Home Phone

Parent / Guardian Information

First Name

Last Name

Relation to child

Daytime Phone Number

First Name

Last Name

Relation to child

Daytime Phone Number

Emergency Contact

Someone we may call in an emergency in the event a parent/guardian cannot be reached. This person would assume responsibility for the child until a parent/guardian was available.

Name (First and Last)

Relation to child

Daytime Phone Number

My child may be picked up by the following people

Name (First and Last)

Relation to child

Name (First and Last)

Relation to child

Name (First and Last)

Relation to child

Other Helpful Information

Name of the church you attend

Any ALLERGIES to food, drinks or pets? (Please be specific)

Is your child up to date with immunizations?

Yes No

MANDATORY All children must be current on their immunizations according to Texas State Vaccine Requirements for Pre-K Facililties on the first day of school. You MUST provide a copy of current immunization record to be enrolled in our MDO program.

Please initial to acknowledge that you have read and understand our immunization policy as stated above.

Name of pediatrician

Phone

Siblings

Name

Age

Name

Age

Name

Age

Pets

Kind

Name

Kind

Name

About Your Child

Special Likes / Dislikes

Child's Fears

Toilet Training Status

Nap Habits

How did you hear about FTBC Mother's Day Out Program?

Media Permission

Throughout the year we will take pictures of your child / children. Please select your permission choice and initial below.

Yes No

Initial

Acknowledgement

I understand that completing this form puts my child on the waiting list only.

Yes, I understand

I understand that I have 30 days from the time I am notified that my child has been placed in a class to pay the $90 registration fee.

Yes, I understand

I understand that the $90 registration fee is NON-REFUNDABLE

Yes, I understand

Payment

Non-refundable $90 Registration fee due for each child you are applying to enroll.

Due to the high volume of applications, please DO NOT PAY YOUR REGISTRATION FEE until you have been notified by the MDO Director, Carol Mann.

Children will be placed in a class as space is available on a first come, first served basis.

Notifications of placement will begin mid-March.

Please Select $0

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

If you have any questions, please contact the church office.

MDO Registration Fall 2020 / Spring 2021

Description

Please Fix the Following