Download Application

You may download an application for Mother's Day Out in either Microsoft Word or PDF format.

Application in MS Word

Application in PDF

Child's Name: *


Home Address (Street, City, State, ZIP): *


Home Phone: *


Email Address: *


Child's Birthdate: *


Enrolling for Tuesdays:

Enrolling for Wednesdays:

Enrolling for Thursdays:

Mother's Name: *


Employer: *


Mobile Phone: *


Day Phone: *


Father's Name: *


Employer: *


Cell Phone: *


Work Phone: *


Child's Physician: *


Physician's Phone: *


Hospital Preference: *


Health Problems/Allergies:


First Emergency Contact (provide relationship and phone numbers):


Second Emergency Contact (provide relationship and phone numbers):


Third Emergency Contact (provide relationship and phone numbers):


The following people (up to 4 names) are authorized to pick up my child (in addition to parents):


By checking the following button, if a medical emergency occurs and I cannot be reached, I authorize the persons in charge of the CUMC Mother’s Day Out to take my child to the nearest emergency room and/or call my physician. I assume all financial responsibility for any accidents occurring while at Mother’s Day Out or on the premises of Choctaw United Methodist Church. *

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