Enrollment Waiting List

Middletown United Methodist
Child Development Center
11902 Old Shelbyville Rd
Louisville, KY 40243
(502) 254-5191
mumccdc@middletownumc.org

Date ______________________________
Date Needing Care ________________________

Child's Name ______________________________
Birthday/Due Date__________________________

Father's Information
Name: ___________________________________
Address: _________________________________
_________________________________________
Phone: ___________________________________
Occupation: _______________________________
Business Phone: __________________________

Mother's information
Name: ___________________________________
Address: _________________________________
_________________________________________
Phone: ___________________________________
Occupation: _______________________________
Business Phone: ____________________________

Sibling currrently at center? Yes _____ No _____
If yes, Name ______________________________

Member of Middletown United Methodist Church? Yes __ No __

Medical History (please give details and physician information)
Any allergies? _________________________________________
Any physical limitations? ________________________________
Any medications given on a regular basis? _________________
_____________________________________________________
_____________________________________________________
Physician ___________________ Phone ____________________