Enrollment Form

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Parent’s Day Out Enrollment Form 2017 – 2018 School Year Fill out one enrollment form for each participant.

Child’s Name _______________________________Sex _________Date of Birth____________ Home Address ________________________________City ______________Zip Code________ Home Phone_________________ List any allergies____________________________________ Email address ______________________________________________ May we use this email address for communication concerning upcoming events at PDO?______ Home Church____________________________ If none, may we send you information about our programs?______ ______________________________________________________________________________ Mother’s Name____________________________________ Cell Number__________________ Occupation________________________________________ Business Phone_______________ Father’s Name_____________________________________ Cell Number_________________ Occupation________________________________________ Business Phone_______________

Please list here any names of individuals that you authorize to pick up your child.* Name__________________________________ Phone Number __________________ Relationship to Child______________________________ Name__________________________________ Phone Number __________________ Relationship to Child______________________________ *Please note that identification will be required by these individuals, in the event they pick up child. A non-refundable enrollment/supply fee of $75 is due at the time of enrollment and will hold your child’s place in the class. ______________________________________________________________________________ Date of Entry_______________ Enrollment Fee paid ________Cash___ Check No. ________

Child Bio This information is gathered strictly for teacher use to get to know more about a child prior to their arrival in class. Childs full name_____________________________________________ Any nicknames we might use in class____________________________ Sibling names and ages________________________________________ List any allergies ____________________________________________ Has your child ever experienced a class room setting with a group of peers?

Is your child potty training? If so, what can we do to help in that endeavor?

What do you and your child hope to accomplish this year in our PDO program?

What is your child’s favorite toy and/or activity?

Does your child have any fears or phobias?

Does your child have any Speech/language or other developmental issues?

Has your child experienced any life changing or traumatic events recently or that they may still be dealing with, including but not limited to moving, a new baby, divorce, the death of a loved one or pet? Can they eat at a child-height table or does he/she need a highchair? Does your child nap in a crib or a bed? Is there anything your child needs for rest/nap time like pacifier, special blanket, or stuffed animal? (Please bring those items)

Is there anything else we should know that would make your child’s experience more enjoyable?

Thank you for helping us get to know your child better.

Parent’s Day Out Medical Release Form First Baptist Church of Shawnee

PARTICIPANT INFORMATION (Please Print) Name of Participant_______________________________________ Date of Birth_____________ Address______________________________________________ Age____ City_____________________________ State_______________ Zip___________ Telephone Numbers: Home________________ Cell______________ Work______________ Gender: Male_____ Female ______ PARENT OR GUARDIAN (First emergency contact): Name ____________________________

Relationship _______________________________

Address (if different from child) ________________________________________________ City__________________________ State__________________ Zip____________________ Telephone Numbers: Home _______________ Cell________________ Work_____________

ALTERNATE CONTACT PERSON: Name ____________________________

Relationship _______________________________

Address_______________________________________________________________________ City__________________________ State___________________ Zip____________________ Telephone Numbers: Home__________________ Cell________________ Work___________ HEALTH INSURANCE If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your child is at the activity. Do you have health insurance? Yes____ No ____ Name of Insurance Company______________________________________________________ Policy Number_____________________________ Group Number_______________________ In whose name is the insurance? ____________________________________________________ Family Doctor______________________________ Telephone number____________________ Address_______________________________________________________________________

HEALTH HISTORY If participant should require medical attention for injuries received or illnesses contacted prior to activity, please send us the necessary information to give him/her proper medical care during his/her time with First Baptist Church of Shawnee ministry activities. Pre-existing or present medical conditions: __________________________________________________________________________________________ __________________________________________________________________________________________ Name and dosage of any medications that must be taken: __________________________________________________________________________________________ __________________________________________________________________________________________ Any allergies? _____________________________________ to medications?__________________________ ___ hay fever ___ heart condition ___ asthma

___ diabetes ___insect stings

___frequent stomach upsets ___ physical handicap

___ Epilepsy/Nervous Disorders ___past major illnesses

If any of the above are checked, please give details (i.e. include normal treatment of allergic reactions) __________________________________________________________________________________________ __________________________________________________________________________________________ Any activity restrictions? Yes____ No____ What are they? _____________________________________________________________________________

I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency, I hereby give my permission to the appointed staff that is with my child to obtain medical assistance for my child. I also give permission to the physician or dentist selected by the activity leader to hospitalize and to secure proper medical treatment for my child. This form is in effect for the duration of one year from the date it is signed. If any information changes prior to one year, a new form is required at that time. Parent/Guardian Signature_______________________________________________ Date________________

Dear parents, Bumps, bruises, and sun exposure happen in a toddlers busy world. Please fill out the form below to give permission for us to treat minor injuries, and apply sunblock as a preventative measure I,____________ ______________ , give the PDO staff at FBC Shawnee permission to administer the following medications to my child, as needed. Name:_________________________________ Date:_________________________ ____Sunblock (coppertone/banana boat) ____topical antiseptic/analgesic (like Neosporin) ____band-aids ____childrens Tylenol ____topical/oral antihistamine (such as Benadryl)

Photo Release Form First Baptist Church of Shawnee 11400 Johnson Drive Shawnee, KS 66203 Permission to Use Photograph Event: Parents’ Day Out Location: First Baptist Church of Shawnee, 11400 Johnson Drive, Shawnee, KS 66203 I grant to First Baptist Church of Shawnee, the right to take photographs of me and my family in connection with the above-identified event. I authorize First Baptist Church of Shawnee, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that First Baptist Church of Shawnee may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I have read and understand the above: Signature _________________________________ Printed name ______________________________ Address __________________________________ Date _____________________________________ Signature, parent or guardian _______________________ (if under age 18)