Immaculate Heart of Mary Registration

Staff Contacts

Director
LeAnn Rockwell
lrockwell@diojeffcity.org

Immaculate Heart of Mary Child Development Center
601 Scott Station Road
Jefferson City, MO 65109

573-644-9177

IHM - Immaculate Heart of Mary Registration Form

Who is completing this form?(Required)

Parent

Grandparent

Other

Please describe your relationship to the child to be enrolled in Immaculate Heart of Mary Child Development Center.

Please describe your relationship to the child:(Required)

Child Information

Child's Name(Required)

First Middle Last

Date of Birth(Required)

Sex(Required)

Male

Female

Please click here to access the medication authorization form and complete the form with the child's information. Then, upload the form using the "Upload file" button below.

Please upload the medication authorization form:(Required)

Drop files here or

Max. file size: 4 MB, Max. files: 5.

Parent 1/Guardian Information

Parent 1/Guardian Name(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone(Required)

Email(Required)

Employer(Required)

Employer Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone(Required)

Parent 2/Guardian Information

Parent 2/Guardian Name(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone(Required)

Email(Required)

Employer(Required)

Employer Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone(Required)

Does child reside:(Required)

With mother

With father

With both parents

Are there any legal custody guidelines in place?(Required)

Yes

Custody Guidelines File Upload(Required)

Max. file size: 4 MB.

Please provide a copy of the legal custody guidelines by uploading them here.

Persons authorized to pick up child from Immaculate Heart of Mary Child Development Center (other than parents)

Please list two individuals other than the child's parents that are authorized to pick up the child from Immaculate Heart of Mary Child Development Center.

Name - Person #1(Required)

First Last

Relationship to Child - Person #1(Required)

Please list this individual's relationship to the child.

Address - Person #1(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone - Person #1(Required)

Name - Person #2(Required)

First Last

Relationship to Child - Person #2(Required)

Please list this individual's relationship to the child.

Address - Person #2(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone - Person #2(Required)

Terms and Conditions

Please review the following statements and mark your consent by choosing the appropriate option or typing your initials in the blank underneath the statement.

Please click here to access the parent handbook. After reading the handbook, complete the question below. Note: You do not have to upload the medical forms again. They are included with the handbook for your reference.

Please indicate your compliance below:(Required)

I have read and agree to the guidelines stated in the Immaculate Heart of Mary Child Development Center parent handbook.

I agree to allow Immaculate Heart of Mary Child Development Center and the Diocese of Jefferson City to take pictures of my child while at the facility. All photos are property of Immaculate Heart of Mary Child Development Center and may be used by Immaculate Heart of Mary Child Development Center and/or the Diocese of Jefferson City in newsletters, on the website, in social media communications, etc. Through such agreements, I understand that I will not be entitled to compensation nor shall my child be entitled to compensation.

Consent(Required)

I agree to the above statement and give permission according to these terms.

I do not give permission

I understand that I am responsible for complying with all policies included in the Immaculate Heart of Mary Child Development Center Parent Handbook and the Diocese of Jefferson City School Policy and Regulation Manual.(Required)