Statement Of Cooperation printable pdf download

Statement Of Cooperation

Child’s Last Name _____________________________ First ________________________ Middle _________

Child’s Address _________________________________ City _________________ State _____ Zip ________

Birthdate ___/___/___ Phone ______________________

Y/N

__________________

Church member?

Where

Previous Childcare (if applicable) _______________________________________________________________

Medications taken regularly ____________________________________________________________________

Allergies/Reactions___________________________________________________________________________

(Required fields for billing purposes)

Father’s Name __________________________________ SS# __________________ Birthdate ___/___/___

Address

Same as child

Other ___________________________________________________________

Employer ______________________________________________

Work phone _______________________

Cell phone _____________________________

E-mails Address ____________________________________

(Required fields for billing purposes)

Mother’s Name _________________________________

SS# __________________ Birthdate ___/___/___

Address

Same as child

Other ___________________________________________________________

Employer ______________________________________________

Work phone _______________________

Cell phone _____________________________

E-mail Address _____________________________________

Statement of Cooperation

In making application for my child, I take full responsibility for all weekly and/or monthly fees incurred in regards to my child’s

enrollment at Firm Foundations. I understand that there are no refunds on registration fees (materials included). I will also give

a two week written notice upon leaving this program along with the full tuition for the remainder of my term.

I also give permission for my child to take part in all school activities and absolve the school/church from liability to me or my

child because of any injury to my child at school/church or during any activity.

Parent’s Signature ____________________________________________

Date _____________________

_____________________________________________

Date _____________________

Statement Of Cooperation