Night Drop Off Form Child Information:Child’s Name:(Required) DOB :(Required) MM slash DD slash YYYY Nickname: Gender Male Female Primary Home Address:Primary Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Information:Parent 1/Guardian 1 Name:(Required) E-mail Address:(Required) Home# CellPhone#:(Required) Text Messaging: (Please initial)(Required) I hereby permit Young Minds in Motion to text message my cell phone number only when important announcements must be communicated, such as emergencies, school closing, and other events that will affect my child’s care. Food Allergy PlanAllergy Info(Required) My child does NOT have a food allergy that requires restrictions or medications. My child does NOT have any allergies. 1. Name of Allergen (pea nuts, eggs, shellfish, etc.) Previous reactions (rash, lip swelling, nausea/ vomiting, difficulty breathing, anaphylaxis;etc.): Dietary Restriction Complete avoidance Avoid in these specific forms: Other recommendations: If other recommendations is checked:Emergency Treatment, if required * Epinephrine Benadryl Other If other treatment is checked:Night Care Fee Price: Payment must be made at the time of sign-up. There are no refunds if not canceled by Friday at 8 amBilling Address(Required) Same as Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card(Required)Card Details Cardholder Name Δ
