Crossroads Garden of Hope Enrollment
Please fill out this form and click submit.
Child's Name
*
Birth Date
*
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Which session?
*
Please select one option.
Spring
Summer
Fall
Day(s) Attending
*
Please select all that apply.
Tuesdays & Thursdays
Tuesdays, Wednesdays, & Thursdays
Will your child be staying for after-hours care? (Open until 4:30 pm, extra fee, no sibling discount)
*
Please select one option.
Yes
No
Mother/Guardian
*
Email
*
This address will receive a confirmation email
Phone (please indicate Home, Cell, or Work)
*
Address (if different from child)
Lives with child?
*
Please select one option.
Yes
No
Shared custody
Father/Guardian
*
Email
Phone (please indicate Home, Cell, or Work)
*
Address (if different from child)
Lives with child?
*
Please select one option.
Yes
No
Shared custody
Other people living in home with child: (indicate relationship next to name-i.e. sister)
*
Child will generally be dropped off and picked up by:
*
Other people who are authorized to pick up/emergency contacts (Name and phone number) (Anyone who is not the usual person to pick up may be required to show drivers license before leaving with your child.)
*
Please list any person(s) who are UNAUTHORIZED to pick up your child
*
Allergies
*
Other health concerns
*
Changes/events/issues (i.e. death in the family, new baby, etc.)
*
Prior group experience
*
Do you authorize your child to be photographed? These photos may be shared on Garden of Hope - Crossroads MDO Facebook page.
*
Please select one option.
Yes
No
Do you authorize Garden of Hope - Crossroads staff to walk your child to Pantego Park behind the building?
*
Please select one option.
Yes
No
Anything else we should know about your child?
How did you hear about our program?
*
Parent/Guardian Name
*
Today's date
*
I understand that this is a digital signature to complete the enrollment.
*
Please select one option.
Yes
Submit
Description
Please fill out this form and click submit.
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