Trinity Lutheran MOTHERS’ Morning Out
Registration 2012-2013
Child’s Name___________________ Date of Application_________
Nickname____________________________ Birth date_________________
Address________________________ Home Phone____________________
_________________________                Email _____________________
Mother’s Name__________________         Work Number_____________
Occupation______________________        Cell Phone________________
Father’s Name___________________        Work Number_____________
Occupation______________________        Cell Phone________________
List of siblings, name & ages:
______________________     ________
______________________     ________
______________________     ________
______________________     ________
______________________     ________
Religious affiliation_______________________
Nearest neighbor of relative in case of an emergency:
Name________________Phone____________   Name________________Phone_______________
Address__________________________             Address__________________________________
Doctor____________________   Phone_____________
Dentist____________________   Phone_____________
In case of an emergency, my child may be taken to _________________
(hospital)
Food sensitivities______________________________Does your child have asthma?___
Allergies_____________________________________
Any important information you would like to share about your child such as habits, likes, dislikes, illnesses_____________________________________________________________
___________________________________________________________________________
I give my permission for the school to administer first aid to my child, ____________
Signed_______________________.
I give my permission for _________________to participate in any class activity or trip during the school year thereby releasing the school from any liability.
Signed________________________Date___________________
(Please complete opposite page)
Please Check:
Room B2 years old by September 1:    Monday   Tuesday   Wednesday  Thursday    Friday
Room AUnder 2 years old by Sept. 1:   Monday   Tuesday    Wednesday    Thursday
2010-2011 School Year
Registration fee due at the time of application $ 25.00
The school year is divided into 4 sessions. Payments are made during the months of September, November, February and April.  Tuition is based on the number of days per week your child participates in the program.  Bills will be posted outside the classroom at the beginning of each session. The fee per day is $28.00 for the first day. The second day is $27.50
Arrival        9:05 A.M.
Dismissal   11:40 A.M.
At dismissal, my child will be taken home by: ________________________________________________________________
At dismissal, we need to see a driver’s license as proof of identification.
The teachers will list the names of people permitted to pick up the child in the classroom.
Signature of parent_______________________________
Signature of director______________________________
Does your child receive services from Early Intervention?   Yes         No
If yes, please send us a copy of the IEP……..Thank you
If you are interested in speaking to Pastor about joining our church, please check here_____________