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GHBC Preschool & Mother’s Morning Out

Registration Packet

Greater Heights Baptist Church

3790 Post Rd. Cumming, Ga. 30028 (770) 887-4802

General Application

1. Child’s Name:_____________________________

2. Program enrolling child into: ______Mother’s Morning Out Program

______GHBC Preschool

3. Days of Attendance:

Monday_____ Tuesday_____ Wednesday_____ Thursday_____ Friday_____

4. Age:________

5. Sex:________

6. Birth date:_____________

7. Child’s full Address:____________________________________________________

_____________________________________________________________________

8. Phone Numbers of Primary Guardian(s):

a. Home:______________________

b. Cell:__________________

c. Business:______________________

9. Guardian #1 Name:________________________, Relationship:_________________

a. Place of employment:__________________________

b. Address:_______________________________________________________

c. Hours of employment:________________________________

d. Business Phone:____________________________

10. Guardian #2 Name:________________________, Relationship:_________________

a. Place of employment:__________________________

b. Address:_______________________________________________________

c. Hours of employment:________________________________

d. Business Phone:____________________________

11. Marital Status of Parents:

( ) Married ( ) Separated ( ) Divorced ( ) Widowed ( ) Single

12. Child’s Living Arrangements:

( ) Both Parents ( ) Mother ( ) Father ( ) Other

Parental Agreement

1. My child,_____________________, may be released to the following people:

Name: Relationship: Phone Number:

____________________ ___________________ __________________

Name: Relationship: Phone Number:

____________________ ___________________ __________________

Name: Relationship: Phone Number:

____________________ ___________________ __________________

2. If I desire my child to ride home with another parent, who has enrolled their child in MMOP, a signed note must be provided or their name must be added to the release list above.

3. I agree to give my monthly payment of ______ to Greater Heights Baptist Church by the 1^st of each month prior to the upcoming month of instruction.

4. I understand, if I have not paid by the 8^th day of the month my child’s place in the program may be relinquished.

5. I understand, if I have not paid by the 15^th day of the month I am responsible for late charges.

6. I agree to give the Mother’s Morning Out Preschool all necessary information and will notify MMOP of any change pertaining to the administering of medicine to my child (original prescription bottle, doctor’s note, etc.) by filling out a Medication and Authorization Time Card.

7. I understand that my child will be provided with snacks provided by the student’s guardians and will agree to bring snacks for the class as needed.

8. I understand that I must provided a packed lunch for my child each day of their attendance.

9. If my child is required to eat a special diet, I understand that I must provide snacks and lunches that meet his or her diet.

10. I understand that it is my responsibility to escort my child into and out of MMOP and will sign my child in and out.

11. I will provide all needed disposable diapers for my child if necessary.

12. In the case of any planned fieldtrips, transportation will be provided. A separate form and signature must be completed for each year of attendance. The form will need to be signed for each planned trip.

13. My child has the following special need(s):

__________________________________________________________________________________________________________________________________________

14. The following special accommodations would help to most effectively meet my child’s needs while at MMOP:

__________________________________________________________________________________________________________________________________________

15. My child is currently taking medication prescribed for long term use and/or has the following pre-existing illness, allergies, or health condition(s):

__________________________________________________________________________________________________________________________________________

16. I understand that if my child is ill, which includes, but is not limited to: sour throat, severe cough, undetermined rash or spots, temperature over 100 degrees, severe headache, upset stomach, or diarrhea, he or she may not be accepted into the center until he or she has been well for a 24 hour period. If my child obtains these symptoms while attending MMOP the guardian will be immediately notified and asked to pick up the child.

17. I understand that my child will be instructed through the use of the King James Bible during Bible Time and Biblical principles will be used to emphasize Christian Character.

18. My families religious preference is:________________________________________

19. I understand that it is my responsibility to inform MMOP of any change of address, phone numbers, etc.

I agree to abide by all policies and procedures of Mother’s Morning Out Preschool as outlined in this agreement. I have read and understand the above statements.

Signed:___________________________ Date:___________________

(Parent or Guardian)

Signed:___________________________ Date:___________________

(Director of MMOP)

Child Profile

As your child grows and develops this profile should be changed so that the MMOP will be aware of your child’s unique characteristics that could affect teaching styles and preparation. Please write N/A under questions that do not apply to your child.

Child’s Name:__________________________ Birth Date:__________________

1. Does your child go by any other name(s) than what is written above?

__________________________________________________________________________________________________________________________________________

2. Has your child had previous preschool or daycare experiences?

__________________________________________________________________________________________________________________________________________

3. What would you like most for your child to gain from his or her experience in Mother’s Morning Out Preschool?

4. What does your child most enjoy doing?

5. Do you consider your child as shy or out going?

__________________________________________________________________________________________________________________________________________

6. Is there anything that your child fears?

__________________________________________________________________________________________________________________________________________

7. What are your child’s favorite toys?

__________________________________________________________________________________________________________________________________________

8. About what things does your child express the most curiosity?

9. Does your child play well with other children Yes_____ No_____

If No please explain:__________________________________________________________

10. List the names and ages of other children in your family:

__________________________________________________________________________________________________________________________________________

11. What words are used for toileting in your home?

_____________________________________________________________________

12. Does your child need a favorite item while taking a nap? Yes ____ No____

If Yes, what is the favorite item?______________________________________

13. How many hours of sleep a does your child usually receive a night?________________

14. Do you have a special interest or hobby you would like to share with your child?

_____________________________________________________________________

15. Does anyone else care for your children (grandparents, neighbors) Who?

_____________________________________________________________________

16. What language is spoken in your home?

_______________________________

Parent Signature:_______________________________ Date:_______________________

Additional Notes:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Health and Emergency Permission Form

Child’s Name:_____________________________ Birth Date:_________________________

Address:____________________________________________________________________

Primary Contact Number: ___________________________________

1. Does the child have physical problems, mental health disorders, or developmental disabilities?

Yes_____ No______

If Yes, specify:_______________________________________________________________

2. Does the child have any allergies? (food, medication, insects, etc.)

Yes_____ No_____

If Yes, specify:____________________________________________________________________

3. Are there any special procedures that are required in caring for the child?

Yes:_____ No:_____

If Yes, specify:____________________________________________________________________

Emergency Contacts: (Place in the order of preferred notification)

Name:	Relationship:	Home Phone:	Cell:
1.
2.
3.
4.

I, _______________________________, give my permission to Greater Heights Baptist Church and the Mother’s Morning Out Preschool Program to seek medical attention for my child, ____________________________________________, in the event of an emergency if I cannot be contacted. I agree to hold harmless and release Greater Heights Baptist Church and the Mother’s Morning Out Preschool from all liability. I further agree to keep the facility informed of changes in telephone numbers, etc. where I can be reached.

Parent Signature:____________________________________ Date:________________________

Mother’s Morning Out Preschool emergency medical procedure:

1. Contact Guardian

2. Contact Person Listed as Emergency Contact if guardian cannot be reached

3. Call Emergency Medical Team, if necessary

4. Have Emergency Medical Team transport to the nearest hospital

(If emergency occurs at preschool the child will be transported to: Northside Hospital, 1200 Northside Forsyth Drive Cumming, Ga 30041 Phone: (770)884-3246)

***Remember if your child is taking any type of medication an authorized time sheet must be filled out

Photo Release Form

I hereby grant my permission to personnel working at or with Mother’s Morning Out Pre-school to take photos of my child/children that may be used in publications, on church affiliated websites or presentations.

I hereby waive my right to inspect and/or approve of finished products.

I hereby release any person working at or with Mother’s Morning Out Pre-school from any liability as a result of blurring, distortion, or alteration that may occur in the taking of or in the production of a photo.

I hereby warrant that I am of full age and competent to contract for the minor named below. I have read and understand the above photo release information.

__________________________________ ____________________________________

Minor’s Name Parent or Guardian

__________________________________ ____________________________________

PRINTED NAME PRINTED NAME

Parent/Guardian Agreement

I have read and understand the contents of the Mother’s Morning Out Preschool Registration Packet and agree to abide by all stated policies and procedures.

______________________________________________

Child’s Name (Print)

______________________________________ ______________________________________

Parent/Guardian’s Name (Print) Signature

Date:_______/________/________

_______________________________________ _____________________________________

Parent/ Guardian’s Name (Print) Signature

Date:_______/________/________

Please Mail or Deliver Registration Forms to:

Greater Heights Baptist Church

433 Canton Rd. Suite 306

Cumming, Ga. 30040

(Until October)

3790 Post Rd.

Cumming, Ga. 30028