Hearts of Moore Parent's Day Out Enrollment Form
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Welcome to our Hearts of Moore family!
Please use this form to enroll your child in our program.

Once you have submitted this form, we will contact you soon with information and next steps! We are so delighted you will be joining us!

A $60 enrollment fee is due to confirm your child's place in the program. Once we have received your enrollment fee and confirmed your child's class and start date with you, your child's place will be reserved.

If you have any questions, please contact or Director of Early Childhood and Children's Ministries, at pdo@moorechurch.com

If you prefer to complete a paper form, it is available here:  https://drive.google.com/file/d/1SXrTuvFPFDEB5GpdFG7db-6Wt14AF74y/view?usp=sharing 

Hearts of Moore PDO is a ministry of Moore 1st United Methodist Church, 201 W. Main Street, Moore, Oklahoma. For more information visit https://www.facebook.com/heartsofmoorepdo.
INFORMATION ABOUT YOUR CHILD
Child's Name
Child's Date of Birth
Child's Gender
Please tell us about your child's allergies / medical issues:
PARENT / GUARDIAN INFORMATION - A
A - Parent/Guardian Name
A - Relationship to Child
A - Email Address
A - Address
A - Cell Phone Number
A - Is it okay to text this cell phone number?
Clear selection
A - Please list any additional contact information for this parent/guardian: (e.g. name of employer & work phone, home phone, etc.)
PARENT / GUARDIAN INFORMATION - B
B - Parent/Guardian Name
B - Relationship to Child
B - Email Address
B - Address
B - Cell Phone Number
B - Is it okay to text this cell phone number?
Clear selection
B - Please list any additional contact information for this parent/guardian: (e.g. name of employer & work phone, home phone, etc.)
ADDITIONAL INFORMATION
Siblings' Names & Ages
Child's T-shirt Size:
How did you hear about our program?
Please select which days you would like your child to attend our program:
PERSONS AUTHORIZED TO PICK UP CHILD (other than parents)
Authorized person 1 -- Name / Relationship to child / Phone Number
Authorized person 2 -- Name / Relationship to child / Phone Number
Authorized person 3 -- Name / Relationship to child / Phone Number
PARENT/GUARDIAN CONSENTS
This section must be completed by a legal parent/guardian.
Name of person completing this form
I certify that I am a legal parent/guardian of the child listed on this form.
PHOTO / VIDEO USAGE
As the parent/guardian of the child listed on this form, I consent to allow my child's picture or video taken by or on behalf of Hearts of Moore PDO to be used to promote the program. This may include newsletters, newspapers, flyers, church bulletins, social media, and the church website.  
Do you consent to this photo/video usage?
Clear selection
IN CASE OF EMERGENCY
As the parent/guardian of the child listed on this form, in the event of an emergency, I authorize the staff at Hearts of Moore PDO program to obtain medical care for my child via emergency services or at the nearest medical facility, or otherwise as determined most appropriate.
Do you agree to this In Case of Emergency statement?
Clear selection
This is how I would like for Hearts of Moore PDO to obtain medical care for my child in the event of an emergency:
MEDICAL INFORMATION
Child's Physician:
Physician's Address:
Physician's Phone Number:
Health Insurance Carrier:
Policy Number
Group Number:
Name of Primary Insured:
Vaccination Record
Please provide a copy of your child's vaccination record. There are several ways to do this-- please indicate which you would like to use!
I will provide a copy of my child's vaccination record by
Clear selection
TELL US ABOUT YOUR CHILD
How would you describe your child?
What should your child's teacher know about your child?
What are your child's fears?
Is your child potty training?
Is there anything else you would like us to know?
Submit
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