PDO & Preschool Program Registration Child's Name* First Last Preferred NameAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child's Date of Birth* Date Format: MM slash DD slash YYYY Child's Age on August 15, 2021*Is there any information that we need to know about your child?(Special health or developmental concerns, allergies, fears, etc.)Child's T-shirt Size*XSSMLXLHow did you hear about our program?*Family/FriendInternetFacebookChurch SignParent/Guardian InformationMother's Name* First Last Marital StatusOccupationAddress(if different from child) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Home PhoneWork PhoneEmail Address* Are you on Facebook?YesNoFather's Name* First Last Marital StatusOccupationAddress(if different from child) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Home PhoneWork PhoneEmail Address* Are you on Facebook?YesNoPersonal InformationPlease list siblings’ names and ages:NameAge Does your family attend church?*YesNoWhat church does your family attend?Has your child ever been in a childcare or preschool program?*YesNoWhat program(s) did your child attend?Please list the name and phone number of at least two people (other than parents) who are allowed to pick up your child.*If we need to contact you and cannot reach you, we will call these people in the order listed.Allergy & Medical InformationMy child has known health problems which would affect his/her school day.*YesNoMy child's health-needs include the following conditions: Select All Allergies ADD or ADHD (diagnosed) Asthma Diabetes Hearing or vision problems Seizures Other Please specify your child's kind of allergies:*SeasonalBeesFoodPlease specify your child's diabetic condition:*Type 1Type 2Takes InsulinPlease specify the type of seizure(s) your child has had:*Date of child's last seizure* Date Format: MM slash DD slash YYYY Child's Doctor* First Last Phone Number for Child's Doctor*Hospital Preference:Please list any medications your child takes on a regular basis:Please list any other health information for your child:Permission for PhotographsAll photographs taken at Ball Camp Baptist Church will be used within the program for displays and/or for our church’s website and Facebook page. We will never post your child’s name or any personal information about your child with any of their pictures.Permission*Yes, photos may be taken of my child and used in displays, advertisements, on the church website, and on BCBC PDO and BCBC Facebook pages.No, photos may not be taken of my child and used in displays, advertisements, on the church website, or on BCBC PDO and BCBC Facebook pages.Parent/Guardian Signature*Date* Date Format: MM slash DD slash YYYY Potty TrainingWe realize that all children attending our program are at different stages of potty training. Please check the appropriate box for your child’s potty-training routine. We will assist all children in their potty-training routines any way we can.Potty-Training Routine Details***Please note: Your child MUST be potty-trained before entering into our 3-year-old class.My child is in diapers.My child is in pull-ups, but is beginning to potty train at home. Please take my child to the potty and provide assistance.My child is fully potty trained. However, if he/she needs assistance, I give the staff permission to assist my child.My child is fully potty trained and does not require assistance. I do not give the staff permission to help my child. I do realize by choosing this option, I will be contacted if my child has an accident and will need to come to the school to change my child.Please specify your child's kind of diapers* Cloth Disposable Registration ChecklistPlease check the box next to each statement after reading.*You may view the Parent Handbook and COVID guidelines on our website. Select All I understand that my registration fee, totaling $150.00, is non-refundable. I also understand that filling out this form and paying my registration fee does not guarantee a spot in the program. However, if a spot is not available for the beginning of the 2021/2022 school year, my check will be held and not deposited until a spot becomes available. I understand that the registration form and fee are for the 2021/2022 school year only. Forms must be completed and fees must be paid for each school year. I understand that registration is a “first come, first serve” basis. If my child is not placed in a class upon registration, he/she will be placed on a waiting list until a spot becomes available in the appropriate class. I understand and have read the Parent Handbook, available on the website. I also understand that changes may be made throughout the school year and I will be kept informed of these changes. I understand that Ball Camp Parents’ Day Out & Preschool is a Christ-centered program and that Biblical values will be taught. I understand and have read the COVID Guidelines, available on the website. I also understand the changes may be made throughout the school year and I will be kept informed of these changes. I understand that I will need to supply a copy of the child's birth certificate and up to date immunization records at Meet the Teacher. Parent/Guardian Signature*Date* Date Format: MM slash DD slash YYYY Registration PaymentPayment*The registration fee is $150. Please note that you will be charged the $4.79 processing fee. Price: $ 154.79 Total $ 0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name