Mother’s Day Out 2016-2017 Student Enrollment Forms

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EMERGENCY CONTACT INFORMATION

PICK-UP PERMISSIONS

What other parties are preauthorized to pick up your child?

PERMISSION AGREEMENTS

EMERGENCY/MEDICAL AGREEMENT:

By typing my name below, I/we grant permission for authorized school personnel to take whatever steps are necessary to obtain medical care if warranted.

Along with the medical release form I agree to the following. Please note these steps may include, but may not be limited to:

  • Attempt to contact child’s primary, secondary, and emergency contacts listed with Mother’s Day Out.
  • Call 911
  • Take the student to an emergency center.
  • Call Ambulance to transport
  1. I understand that any expense incurred will be the responsibility of the child’s family.
  2. I understand that Mother’s Day Out or Capitol Hill Assembly of God will not be responsible for anything that may happen as a result of false information given at the time of enrollment.

PHOTO AGREEMENT:

By typing my name below, I/we grant permission for child to be included in any photos Mother's Day Out may use for:

PAYMENT CONTRACT

ENROLLMENT/SUPPLY FEES
The enrollment fee is a deposit which guarantees my child’s space for the session and is NOT REFUNDABLE should I decide to withdraw my child from Mother’s Day Out. The enrollment/supply fee is charged each semester.

PAYMENT METHOD
Families will make all payments directly to Capitol Hill Assembly. Payments will be accepted in the form of personal check, money order, cash, or Debit Card. For mailing purposes our address is: 2400 SW 74th, OKC, OK 73159. Checks can be made out to Capitol Hill Assembly.

  • All payments are due on the 1st of the month and are considered late if not received by the 10th.
  • All delinquent accounts will incur a $10 late fee. All returned checks will incur a $30.00 returned check fee.

Tuition payments are August through May. Full tuition will be charged September through May, August and December are pro-rated. Please note the Mother’s Day Out schedule (breaks, holidays, etc.) has been taken into account in the establishment of all tuition fees and will not, therefore, be adjusted or pro-rated. Tuition can be paid in a lump sum or monthly. There are NO REFUNDS for missed days due to sickness, weather or scheduled holidays.

Withdrawing from Program
A two week notice shall be given to the Mother’s Day Out Director if I plan to withdraw my child at any time. I am obligated to pay for any or all tuition and fees due prior to withdrawing my child.

By completing the information below and typing my name, I agree to the aforementioned payment contract.

MOTHER'S DAY OUT HEALTH/MEDICAL INFORMATION/RELEASE

By typing my name below, I/we, the undersigned parent(s) or person/people holding legal custody or the legal guardian of the child listed below DO HEREBY AUTHORIZE the staff and/or sponsors of Mother’s Day Out, TO TRANSPORT to medical facility or call ambulance if needed for transport. I/WE CONSENT TO any x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care to be rendered to the above named child under general or special super-vision and upon the advice of a physician, surgeon, or dentist licensed under the laws of the State of Oklahoma.

IN GIVING THIS CONSENT I/WE RECOGNIZE AND UNDERSTAND that in situations where the above named student requires immediate medical or hospital care it may not be possible to contact me/ that and, us in such situation. I/we will not be able to make a knowledgeable evaluation and choose among the available alternative treatments, if any, or to evaluate the risks attendant upon each, and the risks attendant to foregoing all treatment; in such situations, I authorize a physician, surgeon, or dentist to exercise his/her professional judgment and access the risks incident to and choose the necessary treatment from any available alternatives and to render such care and perform such treat-ment as she/he in this professional judgment determines to be necessary for the health or safety of the above named student.

A copy of this consent shall have the same affect as the original.