Alpha-Omega Registration

Before and After School Kids Care Program

(402) 492-8374 ~ www.mhchurch.org

ENROLLMENT APPLICATION

Name of Child __________________________________ Sex: M F Date: ___________

Birth date ___________ Date Care Began ____________ Date Care Terminated___________

Parent or Guardian – Home address and employer address

Mother (or guardian):

Name: ____________________________ Employer: _____________________________

Address: ___________________________ Address: ______________________________

City/St/Zip: ________________________ City/St/Zip: ____________________________

Phone: ___________________________ Phone: ________________________________

Cell Phone: _______________________ Driver’s Lic.#: __________________________

Father (or guardian):

Name: ___________________________ Employer: _____________________________

Address: __________________________ Address: ______________________________

City/St/Zip: _______________________ City/St/Zip: ____________________________

Phone: __________________________ Phone: ________________________________

Cell Phone: _______________________ Driver’s Lic.#: _________________________

Enrollment Application Should Be Mailed With Registration Fee To:

Miracle Hills Church

Attn: Alpha & Omega

11244 Blondo Street

Omaha, NE 68164