2017-2018 School Year
Enrollment Form

To enroll your child in this year's Mothers Day Out program at Westmoreland Baptist Church please fill out the enrollment form below.  We will send you follow-up information about class details, etc very soon. 

Child Name *
Child Name
Address *
Address
Child Date of Birth
Child Date of Birth
Parent / Guardian Information
Parent/Guardian Name *
Parent/Guardian Name
Primary Phone *
Primary Phone
Parent/Guardian Name
Parent/Guardian Name
Primary Phone
Primary Phone
ALLERGIES / MEDICAL
EMERGENCY CONTACT INFORMATION
NAME THREE PERSONS WHO WOULD ASSUME RESPONSIBILITY FOR YOUR CHILD IN AN EMERGENCY WHEN MDO STAFF IS UNABLE TO CONTACT PARENT/GUARDIAN(S). THESE INDIVIDUALS WILL ALSO BE THE ONLY THREE INDIVIDUALS OTHER THAN PARENT/GUARDIANS WHO CAN PICK YOUR CHILD UP FROM MDO.
NAME
NAME
Phone
Phone
NAME
NAME
Phone
Phone
NAME
NAME
Phone
Phone
DAYS OF ATTENDANCE
What days will child attend? *
Select all days child will attend MDO.
Were you referred to MDO by someone?
Were you referred to MDO by someone?