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Westminster Presbyterian Little Learners Monday - Wednesday - Friday 2006-2007 Registration Form 471-9995
Child’s Full Name: _______________________________________
Birthdate: _____________________________________________ Month Day Year
Father’s Cell Phone ______________Mother’s Cell Phone ______________
Name of child’s physician____________________Phone________________
Persons who can be contacted if parents are unavailable:
1.__________________________________Phone____________________
2.__________________________________Phone____________________
Any known Allergies?____________________________________________
In the event that my child is injured while attending Mother’s Day Out, I absolve Westminster Presbyterian Church and all persons involved with this program any responsibility relating to any accident
incurred.
____________________________________________________________
Parent Signature Date
*If Mom’s Day Out is needed for Tuesday and Thursday, please complete a separate Mom’s Day Out registration form.
Immunization Record and Fees required for enrollment.
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