For your convenience, you may print, complete, and return this form to our office.
 

OFFICE USE ONLY
 
Date and Time ________________ Received by ______________
     
Amount Paid $ ______________   Check or Cash _______
 
2011 SUMMER MEADOWOOD KIDS MOTHER'S DAY OUT
ONLINE REGISTRATION FORM

Child's Name
M / F
Age
Grade
Birthdate (inc. year)
           
(in fall)
   
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Parent's Name __________________________________________________________________________
 
Address _______________________________________________________________________________
 
City: __________________________________ State: ______________________ Zip: ________________
 
Phone Numbers: Home: __________________ Cell: __________________ Work: __________________
 
Cell Phone No. _________________________________________________________________________
 
Emergency Contact Name and Number: _________________________________________________
 
Both Tuesday and Thursday _____ ---------- Tuesday Only _____ ---------- Thursday Only _____
 
 
If you have not filled out a Medical Release Form for this school year for your child(ren) please obtain one from the director, complete it, and return it. We need one for each child going on field trips and each child that stays here.
 
I agree to read the MEADOWOOD KIDS MOTHER'S DAY OUT Policies and abide by them.
 
Signed ______________________________________________
 
 
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