Name of Child (last, first, middle initial)

Date of Birth

Sex Sex Male Female

Grade

School

Requested Start Date (if different from first day of school)

Kindergarten Extended Day (KED) - first come, first served enrollment, with limited spaces available Kindergarten Extended Day (KED) - first come, first served enrollment, with limited spaces available Monday Tuesday Wednesday Thursday Friday

To help us provide the most appropriate care and supervision for your child, please inform us as to whether your child have any special needs (ex. physical, emotional or developmental) which may require accommodation by our program. If so, please detail those needs and consider providing MSCCOS authorization to discuss with the child’s teacher, Haddonfield Child Study Team, and principal as necessary.

Check here to give authorization for MSCCOS to discuss my child’s needs with Haddonfield school and Child Study Team personnel. Check here to give authorization for MSCCOS to discuss my child’s needs with Haddonfield school and Child Study Team personnel. Yes, I give authorization for MSCCOS to discuss my child’s needs with Haddonfield school and Child Study Team personnel.

Bill to and Primary Contact - Name of Parent/Guardian

Home Address/City/State/ZIP

E-mail Address

Cell Phone

Home Phone

Work Phone (main line AND direct ext.)

Employer

Occupation

Work Address/City/State/Zip

By checking the box below, you are agreeing to all financial responsibility: By checking the box below, you are agreeing to all financial responsibility: I agree to all financial responsibility

Name of Parent/Guardian #2

Parent/Guardian #2 Address/City/State/ZIP (if different from above)

Parent/Guardian #2 Email

Parent/Guardian #2 Cell Phone

Parent/Guardian #2 Home Phone

Parent/Guardian #2 Work Phone (main line AND direct ext.)

Parent/Guardian #2 Employer

Parent/Guardian #2 Occupation

Parent/Guardian #2 Work Address/City/State/Zip

Are there any needs that Mustard Seed Community Childcare at Our Savior can help your family with?

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: Parents are Married Joint Custody Full Custody to Mother Full Custody to Father Full Custody to Other (enter name below)

Name of Full-Time Custodian if not mother or father

Does non-custodial parent have the right to visit the program site or take the child from the program site? Does non-custodial parent have the right to visit the program site or take the child from the program site? Yes No (COURT ORDER REQUIRED) Only with prior written/verbal authorization (COURT ORDER REQUIRED)

Emergency Contact #1 Name* (OTHER THAN PARENTS)

Emergency Contact #1 Address

Emergency Contact #1 Relation to Child

Emergency Contact #1 Cell Phone

Emergency Contact #1 Home Phone

Emergency Contact #1 Work Phone

Emergency Contact #2 Name (OTHER THAN PARENTS)

Emergency Contact #2 Address

Emergency Contact #2 Relation to Child

Emergency Contact #2 Cell Phone

Emergency Contact #2 Home Phone

Emergency Contact #2 Work Phone

Additional person authorized to pick up child

Relation to child

Phone

Additional person authorized to pick up child

Relation to child

Phone

Additional person authorized to pick up child

Relation to child

Phone

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.