2024-2025

Clapps Chapel Parents Day Out Program

August 12 - May 21

Mondays and Wednesdays from 8:30 AM - 1:30 PM

CHILD INFORMATION

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Birthday

YYYY

Siblings/Ages

Allergies/Medical Concerns

Mother's Name

Mother's Phone

(###)

###

####

Mother's Work Phone

(###)

###

####

Mother's Place of Employment

Father's Name

Father's Phone

(###)

###

####

Father's Work Phone

(###)

###

####

Father's Place of Employment

Anything we should know?

For your child's safety, please list persons other than parents to whom the child may be released:

First Name

Last Name

Relationship

Phone

(###)

###

####

Work Phone

(###)

###

####

First Name

Last Name

Relationship

Phone

(###)

###

####

Work Phone

(###)

###

####

First Name

Last Name

Relationship

Phone

(###)

###

####

Work Phone

(###)

###

####

First Name

Last Name

Relationship

Phone

(###)

###

####

Work Phone

(###)

###

####

PERMISSION SLIP

I/We

do hereby give my/our permission for [enter child's name below] to be treated in an emergency by Children's Hospital and/or Knox County Ambulance Service. I/we understand that in case of an emergency, I/We will be contacted as soon as possible.

Parent of Guardian Name and Date

INSURANCE INFORMATION

Name of Insurance Company

Policy Number

Group Number

Parent Acknowledgement

I/We have read the Parent Handbook of Clapps Chapel's Parents Day Out and agree to all terms and conditions listed within its contents.

I understand that this program/facility is exempt and not required to be licensed by the State of Tennessee as a childcare agency.

Parent's Signature and Date

In order to prepare for the program, there is a small fee of $75.00 for registration. Pay this fee now by clicking the button to the right.

2024-2025

Clapps Chapel Parents Day Out Program

Thank you!

Rev. Dr. Chris Stanfield, pastor Richard Wright, lay leader