Lamb of God Lutheran Church
11716 County Line Rd
Madison, Al 35756
256-464-3900
CHILD’S PREADMISSION FORM
FOR MORNING OUT MINISRTY
Child’s Name
Name child is known by
Child’s birth date
Home telephone number
Names of parents or guardians
Address of parent or guardian including zip code
E mail address
Mother’s employer
Work phone
Cell phone
Father’s Employer
Work phone
Cell phone
Person(s) to be contacted in an emergency other than a parent
or guardian- in order of preference
Name
Relationship to child
Address
Child’s doctor and address
Phone #’s
Phone #
1
Names/ages of other children in your home
Brothers
Sisters
Does your family have a home church? _____________
If yes, where is your church? _____________________________
About your child
Does your child need emergency treatment for insect stings? ___
Does your child have any allergies? _____
If yes please list all allergies___________________________
_________________________________________________
Does your child need emergency treatment for allergies? ______
Is your child subject to epilepsy? _______ Asthma? _______
Does your child have any medical problems of which we should be
aware?
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Describe any special needs or instructions which you feel might
help us in caring for your child _________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
2
Toilet Habits
_____Wears disposable diapers _____wears cloth diapers
_____wears pull ups
Is diaper rash a problem? ___ If so how do you treat it? ______
_________________________________________________
Is toddler toilet trained? ___ Is toddler in toilet training? ____
If toilet training, does child indicate bathroom needs? _______
How does your child let you know he/she needs to go to the
bathroom?
__________________________________________
_________________________________________________
Stands at toilet? _____ Sits on toilet? _____
Sits on a potty? ____ How often? _____
_________________________________________________
Does your child need help with toileting?___________________
_________________________________________________
I have read through the Policies and Procedures Handbook for
Morning Out Ministry and I agree to abide by them.
_________________________________________________
Parent or Guardian Signature
Date
3
Emergency Authorization
I give my permission for the Mother’s Morning out
Program to obtain emergency medical
treatment, including emergency transportation for
my child
Name/_____________________________________
If I cannot be reached immediately.
I agree to be responsible for any emergency
medical expenses incurred. To the best of our
abilities, The Morning Out Ministry will exercise
reasonable care and judgment in all matters
related to the welfare and safety of my child.
Parent Signature
Doctor Name
Doctor Phone#
Insurance company
Primary Insured’s date of birth
Policy Number
Group Number
Parent or Guardian Signature
Date
Date
4
Release Form
I release the lead teacher or her designated
representatives, and Lamb of God Lutheran Church’s
Morning Out Ministry from any liability which might arise
as the result of medical service and treatment provided
by any hospital or physician pursuant to such
authorization, it being my desire that my child be
furnished with such medical or surgical services as soon
as possible after the need arises.
I agree to be responsible for any cost of medical service
or treatment of my child as the result of the above
authorization and agree to indemnify and hold harmless
Lamb of God Lutheran Church’s Morning Out Ministry,
the lead teacher or her representatives, from any
expenses incurred for said treatment or services.
______________________________
Parent or Guardian Signature
______________
Date
5
Morning Out Ministry Picture Release Form
Throughout the year we may take
photographs/videos of the children during class
activities.
_____ I hereby grant permission to Morning Out
Ministry (MOM) a Ministry of Lamb of God Lutheran
Church permission to use my child’s (unidentified)
likeness in any photographs, videos made in the course of
regular and special MOM activities or events for any
promotional purpose (including but not limited to, use in
connection with print and electronic media and publication
on the internet) without any obligation to compensate me
or my child.
_______I do NOT give Morning Out Ministry (MOM) a
Ministry of Lamb of God Lutheran Church permission to
use my child’s likeness for promotional purposes.
Child’s name______________________________
Parent’s name (printed) _______________________
Parent’s signature__________________________
Date____________________________________
6
Financial Policy/Agreement Form
____ I agree to pay tuition and fees (including late fees and
penalties for past due accounts) in the amounts specified by
MOM. I understand that the monthly tuition is due on the first
MOM program day of each month.
____I have paid the non-refundable $50.00 registration fee on
this date.____________
____I have received a copy of the parent handbook.
____I have completed the Preadmission, Emergency
Authorization, Release, Picture Release, and Financial Policy
Forms for the MOM program.
____I understand that my child cannot attend without having
The Alabama Immunization Record (blue card) on file.
Parent/guardian signature
Date
7
Address Release Form
Throughout the year a class directory will be
available for parents and MOM use. The directory
will be up dated each time a student is enrolled.
______ I
agree to my name, address, telephone
number and E - mail address being used for a class
and MOM directory.
_____ I do not agree to my name, address,
telephone number and E – mail address being used
for a class and MOM directory.
______________________________
Parent or Guardian Signature
______________
Date
8