2024-2025

Sunnyside Baptist Church

Mom’s Day Out Program Registration

Child's Full Name

First Name

Last Name

Gender

Date of Birth

YYYY

Mother's Name

First Name

Last Name

Preferred Name

Father's Name

First Name

Last Name

Home Address

Mother's Cell Phone

(###)

###

####

Father's Cell Phone

(###)

###

####

Mother's Email

Father's Email

Mother's Employer and Employer Address to include Work phone number and Work Hours

Father's Employer and Employer Address to include Work phone number and Work Hours

Transportation Plan: Persons (other than parents) to whom your child may be released and are authorized to provide transportation for your child. Please include Name, Relationship and Cell Phone number for each

Emergency Contact: (authorized to act on parent's behalf if parents are unreachable in an emergency. Please include Name/Relationship, phone, and address

Child's Physician to include Name, Phone, Medical Concerns/Conditions/Current Medications

Child's Dentist to include Phone

Allergies and Treatment Required. For life threatening allergies, we must have care instructions from the physician on file.

Consent and Authorization for medical treatment 2024-2025

I hereby give my consent to Sunnyside Baptist Church Mom's Day Out Program to act on my behalf in a medical emergency. I understand that every reasonable effort will be made to notify me. If I am unreachable, the emergency contact person noted on my child's registration form will be contacted.

Eating Habits:

What time does your child eat breakfast and lunch? Does your child feed him/herself? Food favorites, food allergies, dietary restrictions

Sleep Habits:

Morning Nap? How long? Special blanket, lovie, etc.

Toilet Habits

Does your child tell you when they need to go? Typical time of bowel movement. Are they able to wipe by themselves or need assistance? Wear a pull-up/diaper (if potty training)

Speech/Physical Development

My child talks: Well, fairly well, not very well, not at all Crawling: Walking: Any concerns about speech or physical development? If so, please explain.

Social Development

How would you describe your child? Outgoing, shy, quiet, talkative, active, happy, grumpy. Is your child around other children on a regular basis? Do you have any concerns about their social development? If yes, please explain.

Any other information about your child that would help us in caring for them?

Parent Agreement - Handbook

I, whose child is listed on this registration, and is enrolled in the 2024-2025 school year of Sunnyside Baptist Church Mom's Day Out program, have received a copy of the Parent's Handbook. I have read and understand the policies and guidelines as described in the handbook, and I agree to abide by them.

Photograph/Video Release Authorization

The undersigned hereby authorizes Sunnyside Baptist Church MDO program, its leaders, to photograph and/or film me and/or my child, and consent to the use of my and/or my child's likeness in any and all publications and/or materials, including, but not limited to, advertising, news media, video and website materials. I further release Sunnyside Baptist Church from and waive any rights that I and/or my child might have to any revenue payment or fee for said photography and/or film.

2024-2025

Sunnyside Baptist Church

Mom’s Day Out Program Registration

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