St. Mary ELC--Mother’s Day Out
Application/Registration Form
Child=s
Name________________________________________________________Nickname___________________________Sex_____________
Family
First
Middle
Date Of Birth_______________________Place_________________________________Birth Certificate Number__________________________
Mailing
Home
Cell Phone or
Address_______________________________________________________Phone#_____________________Beeper# ____________________
(if applicable)
Father=s Name_______________________________________________________Religion__________________________Living?____________
Family
First
Middle
Work
Occupation____________________________________________Company___________________________________Phone#________________
Mother=s
Name________________________________________________________Religion___________________________Living?__________
Family
First
Middle
Work
Occupation____________________________________________Company__________________________________Phone#________________
Parents Separated?_______________
Child Lives with (circle)--
Mother
Father
Both
Legal Guardian
Church
Parish________________________________Baptism___________________________________________________________________________
Date
Church
City
State
List brothers and sisters, their ages, and the school they are presently attending, if any:
Name
Age
School Attending
Name
Age
School Attending
1.________________________ ______ ________________________
3.________________________ ______ ________________________
2.________________________ ______ ________________________
4.________________________ ______ ________________________
Person(s) to contact in case of emergency
if parents cannot be reached_____________________________________________________________Phone#____________________________
Child=s
Physician______________________________________________________________________Phone#____________________________
(OVER)
The following information is being requested so that we may better meet the needs of your child. Please answer the following questions.
Should you answer Ayes@ to any of the questions, please provide an explanation in the space provided.
(circle)
1. Does your child have a chronic illness or disease?
No
Yes,________________________________________________________
2. Does your child have a physical handicap?
No
Yes,________________________________________________________
3. Do you think your child may have a
vision or hearing problem?
No
Yes,________________________________________________________
4. Are there any restrictions, for medical reasons,
on your child=s activities?
No
Yes,________________________________________________________
5. Does your child require prescribed medicine daily ?
No
Yes,________________________________________________________
6. Does your child have any allergies to food?
No
Yes,________________________________________________________
7. Does your child have any other allergies
that we should know about?
No
Yes,________________________________________________________
Please indicate which class you would like your child to enter (mark first two choices):
_____One day(Wednesday) per week _____Two days(Tuesday &Thursday) per week
****The following materials are needed to complete registration:
--Child=s Immunization Records
_____Three days(Tuesday-Wednesday) per week
Saint Mary Early Learning Center * 419 Doucet Road * Lafayette, Louisiana * (337) 984-3750