1 Year Old MDO Class Registration 2023-2024

Class Registration

Please select which class best fits your child by the class age requirement:

Mom's Day Out

One Day ($90/month) Two Days ($165/month) Three Days ($180/Month)

Please choose one, two or three days that your child will attend

Monday Tuesday Wednesday Thursday Friday

Child Information

Child's Full Name (First and Last)

Preferred Name

Sex

Male Female

Age

Birthday

Address | City | State | Zip Code

Home Phone | Cell Phone

Can we include your name, address, e-mail, and telephone number for the class directory?

Yes No

Parent Information

Name of Father/Guardian

Occupation

Employer's Name

Employer's Address

Business Phone

Cell Phone

This address will receive a confirmation email

Name of Mother/Guardian

Occupation

Employer's Name

Employer's Address

Business Phone

Cell Phone

This address will receive a confirmation email

Family Information

Church Attending

Name & Ages of Other Children in the Family

Is This Your Child's First Experience In A Peer Group?

Yes No

Please list concerns about child separation

Emergency Contact Information (other than parents)

Name

Relationship

Home Phone

Work Phone

Cell Phone

Name

Relationship

Home Phone

Work Phone

Cell Phone

Medical Information

Child's Physician

Physician Phone Number

Insurance Information

Insurance Policy #

Child's Dentist

Dentist Phone Number

Emergency Hospital You Prefer

Medical History

Please list any medical conditions your child may have (i.e. asthma, allergies, etc.)

Current Medications

Food/Drink Allergies

Animal Allergies

Please list any other special needs/concerns (i.e. fears, speech/hearing problems, etc.)

I have a current immunization certificate

Yes No

Payment

Deposit (This holds your child's spot) $75

Other:

Reason for choosing our program

How did you hear about our program?

Electric Signature

I consent to the enrollment of my child into the Broadway Baptist Preschool Program, and agree that the Broadway Baptist Church shall not be responsible in case of sickness or in the event that my child is injured while attending Preschool at Broadway Baptist Church. I grant permission for any staff member in charge to administer treatment or obtain necessary medical attention to stabilize my child. I also agree to use my family health insurance as the primary coverage.

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance

Yes No

Please type your First and Last Name

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

1 Year Old MDO Class Registration 2023-2024

Description

Please Fix the Following