MDO Student Application
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: ___________________________________
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:
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.
Thank you, and we hope to meet you soon!
