Registration -

Times: Tuesdays from 9:00am-1:30pm
Location: Worship Center at Crossroads Christian Church Largo - 1645 Seminole Blvd Largo 33778
Coordinator: Dianne Kearney  
Any questions or concerns please contact:  Dianne@crossroadslargo.org   (727)-251-8573

Cost: $25 due each Tuesday your child attends. Additional siblings are $15 each.   
$30 registration fee per family due yearly(not due the first time you attend)
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Child #1 name *
Child #1 Birthdate (mm/dd/year) *
Child #2 Name
Child #2 Birthdate (mm/dd/year)
Child #3 Name
Child #3 Birthdate (mm/dd/year)
Parent #1 Name *
Phone # (Parent 1) *
Parent #2 Name
Phone # (Parent 2)
Parent Email *
Address *
Allergies / medication / special needs
Emergency Contact Name (only if both parents cannot be reached) *
Emergency Contact Phone # *
Who is allowed to pick up your child? (Excluding parents) Please list full names - we will check ID *
Special Instructions - (child has a special blanket to cuddle when they are sad, potty training)
Do we have your permission to occasionally post pictures of your child on the Mom's Day Out Facebook page? *
Required
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