Burtonsville MOPS 2021-2022 Childcare Form

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Please feel out a separate form for EACH child you plan on using childcare for. (For example, if you have three kids and would like childcare for each child, we will need three forms submitted.)

Any questions, please contact us at burtonsvillemops@gmail.com. Thanks!

Last name of child *

First name of child *

Child's date of birth *

YYYY

Does your child have an allergy that we need to be aware of? *

Yes

If you replied "yes", please elaborate. (Please describe the severity, foods that should be avoided, and any other important details we should know. Also, please be specific with any snacks that should not be served as each of our childcare classes will receive a small snack during meeting times.)

Are there any developmental concerns that will prevent your child from participating in age appropriate activities? If so, please explain. *

To best support your child, are there any medical concerns? If yes, please explain. *

In an effort to best protect your child, are there any custody issues that we should be aware of? If yes, please explain. *

Will your child be potty trained by September 1st, 2021? *

Yes

Working on it so maybe

Mother's full name and cell number *

Emergency contact's name *

Emergency contact's number *

By clicking "yes", I agree that the child listed on this application may, without a parent/guardian present, be supervised on the Church of the Resurrection's property by an adult subject to the Archdiocese of Washington's Child Protection and Safe Environment Policy during MOPS-related activities for the 2021-2022 year. *

Yes

Submit

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