Child/Student Info

Register one or more of your children below:

Child's Full name	Child's Gender	Birthdate	Choose Option:	Actions

There are no entries.

Home Address*

Parent/ Guardian Information

Single Parent Household?

Yes

No

1st Parent / Guardian*

Relationship to Child:*

Primary Phone*

Email Address*

2nd Parent / Guardian*

Relationship to Child:*

Primary Phone*

Email Address*

Are parent's divorced?

Yes

No

If divorced, who has legal custody of the applicant **

Please select who should be contacted first if need arises?*

1st Parent/ Guardian

2nd Parent/Guardian

Physician Information

Physician's Name*

Clinic (if applicable)

Clinic/ Physician Phone Number*

Clinic/ Physician Address*

Authorized Person(s) to Pick Up

Please list names of persons authorized to pick up your child(ren)

Person #1 - Authorized to pick up*

Person #1 -Phone Number*

Person #2 - Authorized to pick up*

Person #2 -Phone Number*

Media Release Consent

Please indicate your preference regarding the use of your child’s image in media.

Select one:*

I authorize the use of my child's image in media, including but not limited to print materials, advertisements, and social media, for promotional or educational purposes. I understand that my child’s name or other identifying information will not be used.

I do not authorize the use of my child's image in any form of media.

eSignature*

Mother’s Day Out Registration

Child/Student Info

Parent/ Guardian Information

Physician Information

Authorized Person(s) to Pick Up

Media Release Consent

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