Mother's Morning Out Registration - Siloam Christian Preschool

Child's Name*

First

Last

M/F*

Male

Female

Date of Birth*

day

/

month

/

year

Mom's Name*

First

Last

Mom's Cell #*

Mom's Work #*

Mom's Email*

Mom's Place of Business*

Dad's Name*

First

Last

Dad's Cell*

Dad's Work

Dad's Email *

Dad's Place of Business

Child Lives With*

If Other please list name/relation:

Home Mailing Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Emergency Contact Information

EC 1*

First

Last

EC 1 Cell*

EC 2*

First

Last

EC 2 Cell

Please list any allergies

Single ChoiceDoes your child have an EpiPen?*

Yes

No

Additional Information You Would Like Us to Know

Mom's Morning Out Options

Please choose day(s)*

MMO - (4 days) - $240/month

MMO - (3 days) - $180/month

MMO - (2 days) Mon/Wed - $120/month

MMO - (2 days) Tue/Thur - $120/month

MMO - (1 day) Mon - $80/month

MMO - (1 day) Tue - $80/month

MMO - (1 day) Wed - $80/month

MMO - (1 day) Thurs - $80/month

MMO - (1 day) Fri - $80/month

Registration Fee: $50 ($80 per family)

Materials Fee: $30

Siloam Christian Mother's Morning Out Registration