Registration

Mother’s Day Out Registration

Registration for our summer and fall sessions is now underway. You may submit your registration by simply filling out the form below, or you may print a copy of our registration form by going here.

Family Information

Child's Name:* 
Birthdate:* 

Child's Name: 
Birthdate: 

Child's Name: 
Birthdate: 

Address:* 
City:* 
State:* 

Zip:* 

Home Phone:* 
Cell Phone:* 
Email:* 

Mother's Name:* 

Employer: 
Work Phone: 

Father's Name:* 

Employer: 
Work Phone: 

Emergency Contact Information

In case of emergency, parents will be called first, unless you specify otherwise. Emergency contacts are in addition to parents.

Emergency Contact:* 
Relationship to Child:* 
Phone:* 

Emergency Contact: 
Relationship to Child: 
Phone: 

Medical & Additional Information

Child's Physician:* 

Physician's Office or Group Name:* 
Phone:* 

Does child have any known allergies? If so, explain.

Does child have any special needs? If so, explain.

Is child current on required immunizations?*  yesno

Do you wish to be contacted by Colonial Park Clergy at this time?  yesno

Which session are you registering for:*  SummerFall

Please indicate the days you have chosen:*  MondayWednesdayFriday

Electronic Signature

By entering my name below, I agree to submit the above document with an electronic signature.

Parent's Name:* 
Date:* 

For security reasons, please enter the following text into the field below

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