Seymour United Methodist Church
Parent's Day Out Enrollment Form 2018-2019
Child's Name (First, Middle, Last) *
Your answer
Address *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Parent's / Legal Guardian *
Your answer
Mother's Cell Number *
Your answer
Mother's Email Address
Your answer
Mother's Place of Work & Phone Number *
Your answer
Father's Cell Number *
Your answer
Father's Email Address
Your answer
Father's Place of Work & Phone Number *
Your answer
Emergency Contact *
Your answer
Relationship *
Your answer
Phone Numbers
Your answer
Days Preferred *
Required
Sibling(s) Attending Parent's Day Out
Your answer
Allergies / other medical information needed *
Your answer
Authorized to Pick Up Your Child
Name, Relationship, Phone Number *
Your answer
Pre-Registration
This pre-registers your child for the 2018-2019 school year. Any questions contact Susan Cook @ susan@seymourumc.org, or by calling (865) 705-6893.
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