mdo enrollment — Westmoreland Baptist Church

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

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child Date of Birth

YYYY

List Brother(s) Names

List Sister(s) Names

Previous Preschool Attendance (if any)Special

Special Words Used for "Potty"

Favorite Foods

Parent / Guardian Information

Parent/Guardian Name

First Name

Last Name

Relationship to Child

Email Address

Primary Phone

(###)

###

####

Parent/Guardian Name

First Name

Last Name

Relationship to Child

Email Address

Primary Phone

(###)

###

####

ALLERGIES / MEDICAL

Allergies

Medical Conditions We May Need To Be Aware Of

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

First Name

Last Name

Relationship to Child

Phone

(###)

###

####

NAME

First Name

Last Name

Relationship to Child

Phone

(###)

###

####

NAME

First Name

Last Name

Relationship to Child

Phone

(###)

###

####

DAYS OF ATTENDANCE

What days will child attend?

Select all days child will attend MDO.

Monday

Wednesday

Friday

Were you referred to MDO by someone?

First Name

Last Name

2017-2018 School YearEnrollment Form

2017-2018 School Year
Enrollment Form