Registration Form

Child Information
First Name*
Last Name*
Birthdate*
Gender	Male Female
Medical Notes: Does your child have any allergy / health concerns or special needs?	Yes No
Medical Notes: If yes, what are they?
Legal Concerns: Does your family have any legal / custody concerns?*	Yes No
Legal Concerns: If yes, what are they?
Parent / Guardian Information
Parent / Guardian Name*
Parent / Guardian Address*	Number, Street, City, State, Zip
Parent / Guardian Email*
Parent / Guardian Phone*
Parent / Guardian Alternate Phone
Parent / Guardian 2 Name
Parent / Guardian 2 Address
Parent / Guardian 2 Email
Parent / Guardian 2 Phone
Parent / Guardian 2 Alternate Phone
Emergency Contact Information
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Alternate Phone
Current immunizations are required for Parents' Morning Out attendance. I certify that my child is up to date on his/her vaccinations and will provide a shot record upon request.*	Please initial.
Physician Name
Physician Phone
Hospital Preference
Consent
Photo Release: I give permission for my child’s photo to be taken while in attendance at The Learning Tree.*	Yes No
Classroom Photos: If you answered yes to the previous question, do you give permission for those photos to be used within the classroom, to include, but not limited to newsletters, emails, bulletin boards, and portfolios.	Yes No
Publicity Photos: If answering yes to the previous two questions, do you also give permission for your child’s photo to be used for publicity purposes, including, but not looking muted to brochures, social media posts, or newspaper articles?	Yes No
Policies & Procedures: I have read and will comply with The Learning Tree: Parents’ Morning Out Policies & Procedures outlined in the New Family Handbook.*	Yes

Other Information: Is there anything else we should know to help your child have a successful visit to PMO?
How did you hear about PMO?
If you heard about us from a friend, please tell us who, so we can say thank you!

Child Information

Parent / Guardian Information

Emergency Contact Information

Consent