First Methodist Church Pampa Mother's Day Out

Your $30 registration fee MUST be received at the church for your application to be complete. Church office hours are Mon-Fri, 8AM tp 5PM.

Application for Registration

Child's Name

Date of Birth

Address

Phone

This address will receive a confirmation email

Child lives with:

Both Parents Mother Father Guardian

Father's Full Name

Occupation

Church Membership

Business Address

Business Phone

Cell Phone

Mother's Full Name

Occupation

Church Membership

Business Address

Business Phone

Cell Phone

Other Children in Family (Please list Names and Ages)

Emergency Phone of Neighbor or Friend

Name of PREVIOUS nursery or pre-kindergarten attended and HOW LONG attended

Permission For Field Trips

Children may be taken on supervised and planned excurions. The children are provided insurance coverage by the church. You will be notified in advance, but your one-time permission is requested.

Note: You will also be asked to sign a physical copy of this form.

"I give my permission for (child named above) to attend any field trip planned and accompanied by teachers and assistants of First Methodist Pampa Mother's Day Out Program."

Signature (Your Full Name)

Date

Physical Examination (to be completed by parents)

Child's name and age

List Childhood Diseases

Any emotional problems or other information that you feel would help the teacher understand your child?

Allergic to any drugs?

Other Allergies?

Any physical handicap or speech impediment?

Neighbor or friend who could be contacted in your absence (in case of sudden illness)

Phone

Child's Height and Weight

Imunizations

FMC Pampa Mother's Day Out requests that you have the following

Polio Series

Yes No

Date of Immunization or Booster

DPT Series

Yes No

Date of Immunization or Booster

Measles Vaccine

Yes No

Date of Immunization or Booster

Rubella and Mumps Vaccine (recommended but not required)

Yes No

Please give your doctor's name, address and telephone number

Consent to Contact Physician

Note: You will also be asked to sign a physical copy of this form.

"I give my consent in case of emergency (if parent, neighbor, or doctor cannot be reached) for the staff of First Methodist Church Pampa Mother's Day Out Program to contact a physician."

Signature (Your Full Name)

Date

First Methodist Church Pampa Mother's Day Out

Description

Please Fix the Following