Name of Child

Age

Date of Birth

Address

City

Zip

School

Grade

Primary Contact Parent/Guardian Name

Parent/Guardian 1 Cell Phone#

Parent/Guardian 1 Work Phone#

Parent/Guardian 1 Home Phone#

Parent/Guardian 1 Email

Parent/Guardian 2

Parent/Guardian 2 Cell Phone#

Parent/Guardian 2 Work Phone#

Parent/Guardian 2 Home Phone#

Parent/Guardian 2 Email

Choose days: Choose days: Full Week - 5 days ($250) 4 days ($200) 3 days ($180) 2 days ($120) 1 day ($60)

About Your Child: To help us provide the most appropriate care and supervision for your child, please inform us of any allergies or special needs which may require accommodation by our program.

Custody: If parents are divorced or separated, and/or the child is the subject of a court order, a certified copy (signed by a judge) of the most current document must accompany this form. If applicable, please indicate the court ordered custodial arrangement: Custody: If parents are divorced or separated, and/or the child is the subject of a court order, a certified copy (signed by a judge) of the most current document must accompany this form. If applicable, please indicate the court ordered custodial arrangement: Joint Custody Full Custody to Mother Full Custody to Father Full Custody to Other

Please fill in Custody Name

Emergency Contact 1 Name (must be at least 18 years of age)

Emergency Contact 1 Relation to Child

Emergency Contact 1 Address

Emergency Contact 1 Cell Phone#

Emergency Contact 1 Home Phone#

Emergency Contact 1 Work Phone#

Emergency Contact 2 Name (must be at least 18 years of age).

Emergency Contact 2 Relation to Child

Emergency Contact 2 Address

Emergency Contact 2 Cell Phone#

Emergency Contact 2 Home Phone#

Emergency Contact 2 Work Phone#

Person 1 authorized to pick up your child. Under no circumstances will a child be released to any other person without prior authorization by parent.

Authorized Person 1 Relation to Child

Authorized Person 1 Phone

Person 2 authorized to pick up your child. Under no circumstances will a child be released to any other person without prior authorization by parent.

Authorized Person 2 Relation to Child

Authorized Person 2 Phone

Person 3 authorized to pick up your child. Under no circumstances will a child be released to any other person without prior authorization by parent.

Authorized Person 3 Relation to Child

Authorized Person 3 Phone

Name of person authorized to pick up your child. Under no circumstances will a child be released to any other person without prior authorization by parent.

Authorized Person 4 Relation to Child

Authorized Person 4 Phone

Waiver Waiver I certify that my child's physical condition is satisfactory for participating in the Mustard Seed CCOS Fall Camp. I recognize and acknowledge that there are certain risks of physical injury in any recreational program and I hereby assume full responsibility for any expenses as a result of my child's participation in the Mustard Seed CCOS Program.

I agree to I agree to (a) waive and relinquish; (b) fully release and discharge; and (c) indemnify and hold harmless the Mustard Seed Community Child Care at Our Savior and their officers, agents and employees from any and all claims from injuries, damage or loss which may accrue to me on account of my child's participation in the Mustard Seed CCOS Program.

Mustard Seed Community Childcare at Our Savior requests permission to take pictures or videos of your child and permission to use any photographs or video footagefor promotional or other legitimate reason, including newspapers, brochures, website, Facebook, etc. Mustard Seed Community Childcare at Our Savior requests permission to take pictures or videos of your child and permission to use any photographs or video footagefor promotional or other legitimate reason, including newspapers, brochures, website, Facebook, etc. I grant permission I DO NOT grant permission

Handbook Handbook I hereby acknowledge that I have been given to read a Mustard Seed Community Childcare at Our Savior Handbook, which includes: "Information to Parents", Release Policy, Discipline and Termination Policy, Fee % Payment

Parent Notification and Social Media Policy Parent Notification and Social Media Policy I have received and reviewed MSCCOS' policy on the notification of parents/guardians and MSCCOS' Social Media Policy.

I acknowledge that entering my name on this form is the equivalent of my signature. By submitting it I authorize Mustard Seed Community Childcare at Our Savior to process my application.