Rise & Shine MDO Enrollment Form
Please read and answer the following questions. 
Once you have submitted the form you will receive a confirmation email and select your start date. 
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Date *
MM
/
DD
/
YYYY
Child's First and Last Name *
Child's Birthdate *
MM
/
DD
/
YYYY
Primary Guardian #1
First & Last Name
 *
Primary Guardian #1
- Phone Number
- Email
- Home Address
 *
I would like my child to attend: *
Required
Fun Lunches

Chick-fil-a day- $6 (Tuesday)
Pizza day- $4 (Thursday)
 *
Primary Guardian #2
First & Last Name
 *
Primary Guardian #2
- Phone Number
- Email
- Home Address (if different)
 *
Emergency/ Pick-up Contact #1
- Name
- Phone Number
- Relationship
 *
Emergency/ Pick-up Contact #2
- Name
- Phone Number
- Relationship
 *
Emergency/ Pick-up Contact #3
- Name
- Phone Number
- Relationship
 *
Doctor's Name & Office  *
Doctor's Phone Number *
 Allergies or Special Health needs:
Photo Release

We have 2 forms of social media. Facebook & Instagram. 

We have a personal/private parents only Facebook page that you may receive access to after your child's first day. This is one of the ways we share what your child has been doing throughout the week! 
 *
Consent to Treatment

I understand every effort will be made to reach me in the event of an emergency.  If I cannot be reached, I give permission for the Director(s) of Rise and Shine to act on my behalf of my child to receive medical care.  I authorize and consent to medical, surgical, and hospital care to be performed for my child by medial staff to safeguard my child's health. I waive my right of informed consent to such treatment.  I also give permission for my child to be transported by ambulance if needed.
 *
I have read and agree to the Parent Handbook for Rise & Shine MDO. *
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