Kid S Day Out

Kid’sDayOut

Highlands Presbyterian Church

1160 Highland Colony Parkway

Ridgeland, MS 39157

601-853-0636

Child’s Name: ______Male______Female______

Address: ______City:______State ___ Zip______

What name does your child prefer to be called? ______

Birth date: ______Age: ______(as of June1, 2018)

Select age group:

______6 to 12 months ______13 to 18 months ______19 to 24 months

______2 Year Old ______3 Year Old ______4 Year Old ______5 Year Old

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Mother’s Name: ______Father’s Name: ______

Home Phone: ______Home Phone: ______

Occupation: ______Occupation: ______

Cell Phone/Pager: ______Cell Phone/Pager: ______

Work Phone: ______Work Phone: ______

E-mail Address: ______E-mail Address: ______

Religious Affiliation: ______Religious Affiliation: ______

Names and ages of siblings: ______

______

Local emergency contacts and phone numbers if we are unable to reach parents:

Name:______Phone:______Relationship:______

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Does your child have any allergies or special needs: ______

______

In case of a medical emergency: Doctor: ______Telephone Number ______

Insurance Name ______Policy Number ______

Insurance Telephone Number ______

Permission is granted to meet the needs of my child in case of an emergency.

Parent’s Signature: ______

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The following people are authorized to pick up and drop off my child/children:

1. Name: ______Phone: ______

2. Name: ______Phone: ______

I understand that acceptance of this enrollment form and the summer fee of $ 260.00 assures my child a place in Kids Day Out for the Summer of 2018, subject to the rules and regulations of the program. I have read the policy statement and am in agreement with it. I understand that should I decide not to send my child to Kids Day Out the fee is non-refundable.

I do___/do not____ give my permission for my child to be photographed during activities at HMMO.

Parent’s Signature______Date______

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For office use only:

Date Received: ______

Highlands Member ______Previous Student ______Form 121 ______Reg. Fee ______

Date: ______Accepted ______Waiting list ______Acceptance Letter ______