Madison Little Blessings Summer Enrollment 2024

Child Information

Name

Address

Birthdate

Phone

This number will be used in case of an emergency.

Please list any medical concerns/allergies

Please list any rescue medication

Parent Information

First Parent Name

First parent home phone (if different from above)

First parent cell

This address will receive a confirmation email

Place of employment

Work number

Second parent name

Second parent cell

Second parent email

Place of employment

Work number

How did you hear about us?

Madison Programs

Full Day Cost: $60 per day
Mornings only/Afternoons only Cost: $29 per day

Year round: Indicate desired start date

Program Starts June 10, 2024 or later. Indicate Desired Start Date:

Consent

I consent to the use of photography and/or video of my child for classroom use and congregational publicity.

Little Blessings Preschool Prints an annual Student Directory based on the information contained in this form. It is distributed in-house to currently enrolled families. Please indicate below if you wish to be included in the directory.

Directory consent Yes

I consent that my child has permission to participate in all children's ministry activities, under supervision. Good Shepherd Lutheran Church and its personnel will not be held responsible for accidents or personal injury arising there from.*By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this registration form.

Yes

Signature (type name)

Today's date

Registration & Material Fee

This fee is non-refundable and is not applied to tuition. To enroll your child return this form and the fee to the school.

Payment $50.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Madison Little Blessings Summer Enrollment 2024

Description

Please Fix the Following