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Westminster Presbyterian Church Mother’s Day Out
Fall Registration Form
Ages 6 months through 3 years old
Monday - Friday
9:00 a.m. - 1:00 p.m.

Childs Full Name: ______________________________________

Birthday: _____________________________________________

Parent’s Names: _______________________________________

List All Contact Numbers: ________________________________

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Mailing Address, Including Zip Code: _______________________

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Persons who can be contacted if parents are unavailable:

1. _____________________________Phone: _______________

2. _____________________________Phone: _______________

Any allergies? ______________If so, please list: ______________

Please check the days that you would like to enroll your child.

____Monday   ____Tuesday   ____Wednesday   ____Thursday    ____Friday

Click HERE for fees and tution payment information.

Immunization Record and Fees required for enrollment.

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For Office Use Only

____Immunization Record    ____Fees    ____Handbook