EmailMe Form - Mid-Day Movement Fall 2023 Semester Reservation

Child's Name *

First Last

Child's Class *

Please select the days you want to sign your child up for Mid-Day Movement: *

Mondays (8 days)

Tuesdays (8 days)

Wednesdays (10 days)

Thursdays (10 days)

Emergency Contact Information

Please enter the name of the parent or guardian who should be contacted in the case of an emergency.

Emergency Contact Name *

Relationship *

Phone *

### - ### - ####

Emergency Contact Email

By signing your name below, you verify that you are the parent/guardian of the child listed above.

Parent Signature *

First MI Last

Date Time *

MM / DD / YYYY

Parent's Email *

Payment Instructions

Once you hit submit, you will be redirected to our secure online payment page. Please complete payment for $10 per day your child is attending (total days noted below).

All payments are non-refundable. If you are unsure as to the payment amount, contact Monica Signoret at playroom@allsaintsdunwoody.org to verify. Please fill out separate registration form for each child, but pay for entire family's fees at one time. You may "x" out of the payment page after you have already paid your family's fees.

** Remember that all fees are based on using the "ACH Payment Method from your Checking Account." If you prefer to use a credit card, you must select the $15 credit card fee button.