Mother’s Day Out Registration | First Baptist Jackson

I'm New
Ministries
Events
Media
- Worship Services
- Watch & Listen
Resources
Give
Watch

MOTHER’S DAY OUT REGISTRATION

Thank you for your interest in Mother’s Day Out.
To get started, please complete the form below
and we will contact you soon to complete your registration.

CHILD INFORMATION
FIRST NAME*
MIDDLE NAME*
LAST NAME*
NAME USED*
STREET ADDRESS*
CITY*
STATE*
ZIP*
CHILD'S BIRTHDATE*
CHILD'S GENDER*
- Female
- Male
ATTENDANCE
WHICH DAYS WILL YOUR CHILD ATTEND?*
- Tuesday
- Thursday
- Tuesday and Thursday
MOTHER/GUARDIAN INFORMATION
MOTHER'S/GUARDIAN'S NAME
CELL PHONE*
HOME PHONE*
EMAIL*
EMPLOYER
OCCUPATION
WORK PHONE*
CHURCH AFFILIATION
MEMBER?
- Yes
- No
FATHER/GUARDIAN INFORMATION
NAME
CELL PHONE
HOME PHONE
EMAIL
EMPLOYER
OCCUPATION
WORK PHONE
CHURCH AFFILIATION
MEMBER?
- Yes
- No
EMERGENCY CONTACTS
CONTACT 1 NAME*
RELATIONSHIP TO CHILD*
CELL PHONE*
HOME/WORK PHONE*
CONTACT 2 NAME*
RELATIONSHIP TO CHILD*
CELL PHONE*
HOME/WORK PHONE*
OTHER AUTHORIZED PICK-UP PERSONS
NAME
RELATIONSHIP TO CHILD
CELL PHONE
HOME/WORK PHONE
NAME
RELATIONSHIP TO CHILD
CELL PHONE
HOME/WORK PHONE
PHOTO ID REQUIRED FOR PICK-UP*
I understand the person picking up my child will be required to show a photo ID. I will notify the MDO Director each time someone other than the parents/guardians will pick up my child.
- Yes, I understand the requirements for pick-up.
MEDICAL RELEASE
ALLERGIES
DAILY MEDICATIONS*
KNOWN HEALTH ISSUES*
PHYSICIAN'S NAME*
PHYSICIAN'S PHONE*
HOSPITAL PREFERENCE
EMERGENCY INSTRUCTIONS (IF ANY)
INSURANCE COMPANY
POLICY NUMBER
GROUP NUMBER
PERMISSION FOR CONSENT*
In order to meet all legal requirements, I hereby authorize a representative of First Baptist Church Jackson Preschool/Mother’s Day Out Ministries to give consent for any and all necessary medical care for my child while said child is in the custody of First Baptist Church Jackson.
- Yes, I authorize consent for medical care.
PHOTO/VIDEO CONSENT
PHOTO VIDEO CONSENT*
I give permission for images and videos of my child taken during Mother’s Day Out activities to be used solely for the purpose of First Baptist Church Jackson and waive any rights of compensation or ownership.
- Yes, I give permission for images and videos of my child to be used.
- Please do not use images or videos that include my child.
Comments
This field is for validation purposes and should be left unchanged.

Δ

Directions

First Baptist Jackson
431 North State Street
Jackson, MS 39201

Plan Your Visit

@ 2022 First Baptist Church of Jackson Mississippi | All Rights Reserved