Night Drop Off Form Child Information:Child?s Name:(Obligatorio) DOB :(Obligatorio) MM barra DD barra AAAA Nickname: Género Masculino Hembra Primary Home Address:Primary Home Address(Obligatorio) Dirección Dirección 2 Ciudad AlabamaAlaskaSamoa AmericanaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrito de ColumbiaFloridaGeorgiaGuamHawaiIdahoIllinoisIndianaIowaKansasKentuckyLuisianaMaineMarylandMassachusettsMichiganMinnesotaMisisipíMisuriMontanaNebraskaNevadaNew HampshireNew JerseyNuevo MexicoNueva YorkCarolina del NorteDakota del NorteIslas Marianas del NorteOhioOklahomaOregónPensilvaniaPuerto RicoRhode IslandCarolina del SurDakota del SurTennesseTexasUtahIslas Vírgenes de los Estados UnidosVermontVirginiaWashingtonVirginia del OesteWisconsinWyomingFuerzas Armadas AméricasFuerzas Armadas de EuropaFuerzas Armadas del Pacífico Provincia Código Postal Parent/Guardian Information:Parent 1/Guardian 1 Name:(Obligatorio) E-mail Address:(Obligatorio) Home# CellPhone#:(Obligatorio) Text Messaging: (Please initial)(Obligatorio) 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(Obligatorio) 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 Precio: Payment must be made at the time of sign-up. There are no refunds if not canceled by Friday at 8 amBilling Address(Obligatorio) Same as Home Address Dirección Dirección 2 Ciudad AlabamaAlaskaSamoa AmericanaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrito de ColumbiaFloridaGeorgiaGuamHawaiIdahoIllinoisIndianaIowaKansasKentuckyLuisianaMaineMarylandMassachusettsMichiganMinnesotaMisisipíMisuriMontanaNebraskaNevadaNew HampshireNew JerseyNuevo MexicoNueva YorkCarolina del NorteDakota del NorteIslas Marianas del NorteOhioOklahomaOregónPensilvaniaPuerto RicoRhode IslandCarolina del SurDakota del SurTennesseTexasUtahIslas Vírgenes de los Estados UnidosVermontVirginiaWashingtonVirginia del OesteWisconsinWyomingFuerzas Armadas AméricasFuerzas Armadas de EuropaFuerzas Armadas del Pacífico Provincia Código Postal Credit Card(Obligatorio)Detalles de la tarjeta Nombre del titular Δ
