Early Learning Center at WUMC Registration Form

Note that we are currently full for children under 2 years.
I am Registering for (Choose 1 or more)

2018 - 2019 School Year 2019 Summer program 2019 - 2020 School Year
The program I am enrolling in (choose one or both)

Kingdom's Kids Mother's Day Out (ages 6 months - PK) Warrenton United Methodist Preschool (ages 3-5 and fully potty trained)
WUMP ONLY:

3 year old, 3 days 3 year old, 4 days 4 year old, 3 days 4 year old, 4 days 4 year old, 5 days
First Child
Child's Name *

First Name Last Name
Nickname
Date of Birth *

Month Day Year
Date Date Picker Icon
Gender *

Male Female
Birth Certificate Number:
Does your child have any known allergies? If yes, please list allergy, reaction, and treatment *
Does your child have any health issues or concerns in the areas of speech, vision, motor function, hearing? If yes, explain.
Do you have any concerns about your child's development?
Check any of the following illnesses your child has had

Asthma Earaches Mumps Whooping Cough Bronchitis Eczema Pneumonia Polio Chicken Pox Frequent Colds Croup Convulsions Measles Influenza Rheumatic Fever Diphtheria Tonsillitis
Does your child take any medication on a regular basis? If yes, please list name of medication, dosage and medical condition.
Please comment on any additional medical information/special need the child care provider should be aware of:
Second Child
Child's Name

First Name Last Name
Nickname
Date of Birth

Month Day Year
Date Date Picker Icon
Gender

Male Female
Birth Certificate Number:
Does your child have any known allergies? If yes, please list allergy, reaction, and treatment
Does your child have any health issues or concerns in the areas of speech, vision, motor function, hearing? If yes, explain.
Do you have any concerns about your child's development?
Check any of the following illnesses your child has had

Asthma Earaches Mumps Whooping Cough Bronchitis Eczema Pneumonia Polio Chicken Pox Frequent Colds Croup Convulsions Measles Influenza Rheumatic Fever Diphtheria Tonsillitis
Does your child take any medication on a regular basis? If yes, please list name of medication, dosage and medical condition.
Please comment on any additional medical information/special need the child care provider should be aware of:
Third Child
Child's Name

First Name Last Name
Nickname
Date of Birth

Month Day Year
Date Date Picker Icon
Gender

Male Female
Birth Certificate Number:
Does your child have any known allergies? If yes, please list allergy, reaction, and treatment *
Does your child have any health issues or concerns in the areas of speech, vision, motor function, hearing? If yes, explain.
Do you have any concerns about your child's development?
Check any of the following illnesses your child has had

Asthma Earaches Mumps Whooping Cough Bronchitis Eczema Pneumonia Polio Chicken Pox Frequent Colds Croup Convulsions Measles Influenza Rheumatic Fever Diphtheria Tonsillitis
Does your child take any medication on a regular basis? If yes, please list name of medication, dosage and medical condition.
Please comment on any additional medical information/special need the child care provider should be aware of:
Mother's Information
Mother's Name:

First Name Last Name
Home Phone

Area Code Phone Number
Mother's Cell Phone

Area Code Phone Number
Mother's Email
example@example.com

Mailing Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's Place of Employment and Phone Number
Father's Information

Only complete if different from above
Full Name of Father

First Name Last Name
Home Phone

Area Code Phone Number
Father's Cell Phone

Area Code Phone Number
Father's Email
example@example.com

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Father's Place of Employment and Phone Number
Family and Medical Information
Child's Doctor and Phone # *
Names and Birthdates of Siblings
Persons authorized to pick up my child(ren) (include phone numbers and relationship)
Persons NOT authorized to pick up my child(ren) (list custody issues, etc)
Has your child had previous daycare or preschool experience away from home?
Please explain any concerns you may have (i.e fears, nap procedures, special discipline, etc.)
Warrenton United Methodist Church will notify the parent when the child becomes ill or is injured and the parent will arrange to have the child picked up as soon as possible. Parents are required to inform Warrenton United Methodist Church the next business day if the child develops any communicable disease. *

Agree
By clicking "agree" you give permission for Warrenton United Methodist Church employes to apply as needed...diaper rash cream, band aids. 1st aid ointment.

Agree Disagree
Do you have a special talent or skill that you would like to share with us?
We like to take photos of the children playing and doing activities . We occasionally use the pictures in newsletters, outreach brochures, the WUMC website, and social Media. Children's names and/or ages are not used. *

I hereby grant my permission for photos to be used I DO NOT grant permission for photos to be used
Insurance Carrier *
Insurance ID # *
Emergency Contact, Relationship and Phone # *
In the need for evacuation, please hold my child(ren) until the following person arrives *
Is there anything else you would like us to know about your child(ren)?
My child's Birth Certificate and Immunization Records must be on file before my child can enroll *

Agree Disagree
By clicking "agree", you authorize and give permission for your child to be transported to a hospital for evaluation and emergency medical or surgical treatment, including any necessary X-ray examination or diagnostic tests, or administration of medication. In consideration of the arrangements set forth herein, you do on behalf of yourself, your child, and your respective heirs, successors, assigns, and next of kin, release, waive, hold harmless, defend and covenant not to sue, Warrenton United Methodist Church and each of their respective departments, directors, administrators, teachers, officers, agents, representative, volunteers, and employees from any and all actions, claims, demands, or liabilities, including without limitation, those for personal injuries or property damage, that you and/or your child may suffer due to illness or injury suffered by your child as a result of this agreement, including medical treatment and any consequences that may arise as the result of this treatment, to the fullest extent permitted by law. You accept full responsibility for any medical or hospital bills associated with the care of your child. *

Agree Disagree
Signature

Clear
Should be Empty:

Note that we are currently full for children under 2 years.

First Child

Second Child

Third Child

Mother's Information

Father's Information

Family and Medical Information