2022 - 2023 Registration

Child's Name

Age

DOB

Street Address

City & State

Zip code

Parent 1 Name

Phone

Parent 2 Name

Phone

Preferred Email Address (for notification of PDO closings or other important news only)

Is your child allergic to any foods, drugs, bee stings, etc.? If yes, please list all with reaction and treatment:

Medical

Does your child have any special needs or accommodations?

Emergency Contacts other than parents

Name:

Phone

Relationship

Name

Phone

Relationship

Medical Release

In the event of a medical emergency involving my child, (named above), I understand that FPC PDO will make every effort to contact me. If the staff cannot reach me, I give permission for PDO to seek medical attention for my child. Any medical fees incurred will be my responsibility. I agree to hold harmless the Parent’s Day Out program and FPC for their actions on my behalf.

Your Signature

Select a date

Photo Release

I give PDO and FPC Marietta permission to use, print, and/or digital media of my child for promotional purposes.

Your Signature

Select a date