Parents Day Out Registration

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Student's Name *

Address *

Birthday *

Child's Age On September 30

Address 2

City *

State *

Zip Code *

Preferred Contact Name *

Preferred Contact Phone Number *

Preferred Contact Email *

Special Services (List any Special Services your Child receives)

Father's Name

Father's Cell Phone

Father's Work Phone

Father's E-Mail

Mother's Name

Mother's Cell Phone

Mother's Work Phone

Mother's E-Mail

Medical History (List any pertinent medical history, allergies, or concerns)

Is There Anything Else We Need to Know or That Will Help Us With Your Child? (Child's likes, dislikes, tendencies, favorite toy, etc.)

How did you hear about us?

MAKE SURE YOU HAVE SPOKEN TO THE DIRECTOR PRIOR TO REGISTERING YOUR CHILD.

Make check payable to FUMC-DS and place PDO plus child's name in memo line.

Drop off in locked mailbox at Office entrance, or mail payments to:
316 Centerville Street NW
Denham Springs, LA 70726

First and Last *

Date *