Mother's Day Out Fall Registration

For questions please contact Jacqueline Petree at j.petree@rcctulsa.org or 299-1989 x 115
Child's First & Last Name
 
Birthday
 
Sex
Male Female
 
Address
 
City
 
Zip
 
Parent Information
 
Father's Name
 
Occupation
 
Cell
 
Mother's Name
 
Occupation
 
Cell
 
Phone Residence
 
Business Phone
 
Email Address
 
Siblings
 
Others who may be called if parents cannot be reached, please give name, address, and phone:
 
1. Name
 
Address
 
Phone
 
2. Name
 
Address
 
Phone
 
Medical Info
 
Physician
 
Phone
 
Is your child receiving any special medication regularly?
yes no
 
If so, what type?
 
Does your child have any allergies?
 
Are there any restrictions?
 
How did you hear about our program?
 
Costs: $30 enrollment/supply fee due with this application (non-refundable).
 
Select One:
$100 per month, 1 day a week 9 - 2 p.m. Tuesday
 
$100 per month, 1 day a week 9 - 2 p.m. Thursday
 
$110 per month, 2 days a week 9 -12 p.m. Tuesday & Thursday
 
$160 per month, 2 days a week 9 - 2 Tuesday & Thursday
 
 
Register
 
Thank you for registering, if you have any questions please contact Jacqeline Petree at j.petree@rcc
Children