MDO Student Application

Click here to download a printable registration form.

Please print this form

Please circle the correct age:

Baby One Two Three Four Five

Child’s Name: __________________________Called:____________

Birthdate: _________________Age by Sept 2:____________Sex:____________

Address: __________________________________________________________

__________________________________________________________________

Phone Number: ___________________________________

Email Address: ___________________________________

Siblings:___________________________________________________________

Known Allergies: ____________________________________________________

__________________________________________________________________

Parental Information:

Father’s Name: ____________________ Mother’s Name: __________________

Father’s Employer: _________________ Mother’s Employer:________________

Father’s Cell:______________________ Mother’s Cell:____________________

Business Phone:____________________ Business Phone__________________

Child lives with: ____________________________________________________

Please circle what days you would like your child to attend:

(please refer to tuition information to check on availability/offerings for each age)

Monday Tuesday Wednesday Thursday Friday

Other Data:

Local

Church Affiliation: _______Valleydale ____Other Where?_____________

How did you learn about our program?__________________________________

May we photograph your child? _____yes _____no

May we include your address/phone number on a classroom list? ___yes ___no

Please tell us a little about your child: __________________________________

__________________________________________________________________

The following people can pick up my child:

Name Relationship to child Home/Cell Number

_____________________MOTHER____________________________________

_____________________FATHER_____________________________________

_________________________________________________________________

The following people CANNOT pick up my child: ________________________

Please remember, this is an application only. Bring this form into the Mother's

Day Out Office, along with the registration fee, and we will place your child

on our rolls provided there is a place. Please fill out a separate form for each

child.

MDO Student Application

Click here to download a printable registration form.

Please print this form

Please circle the correct age:

Parental Information:

Please circle what days you would like your child to attend:

Other Data:

The following people can pick up my child:

Thank you, and we hope to meet you soon!