PDO Registration Form | Seymour United Methodist Church

If you are a human and are seeing this field, please leave it blank.

2021-2022 Registration Form

Child's Full Name

Address

Date of Birth (mm/dd/yyyy)

Mother's Name

Mother's Cell Number

Mother's Email Address

Father's Name

Father's Cell Number

Father's Email Address

Emergency Contact/phone number

Allergies

Other Info

LIST PERSONS AUTHORIZED TO PICK UP CHILD AND PHONE NUMBER BELOW

PLEASE CHECK THE FOLLOWING. BY DOING SO YOU ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTAND AND AGREE.

In the event of a medical emergency, I understand that every effort will be made to contact mother, father, legal guardian and all emergency contacts listed first. If necessary, emergency personnel (911) will be called immediately to care for your child. The Director of the Class/Program or his/her designee reserves the right to make this decision.

Photographs of my child can be used on the Seymour United Methodist Church Parent's Day Out website, FaceBook page and printed materials. (Names are not used on Facebook or Website).

I have read a copy of Seymour United Methodist Church Parent's Day Out Handbook Policy for the 2021-2022 school year. I agree to abide by the conditions and policies stated therein.

In consideration of my child enrolling at Seymour United Methodist Church Parent's Day Out, I hereby waive any rights and assume all risks for my child contracting COVID-19 at this PDO and further release, indemnify, defend, and forever discharge the Seymour United Methodist Church, the Seymour UMC Parent's Day Out Program, its staff, employees, agents and representatives from any and all liability if your child contracts the COVID-19 virus while at this PDO.

I have been advised and understand that the Seymour United Methodist Parent's Day Out Program is not licensed and is not required to be licensed by the state as a child care agency.

Electronic submission of this form constitutes my signature as a legal binding agreement and that all the above information is correct:

(Electronic Signature)

Date (mm/dd/yyyy)