Backyard Kids Club 2020

If you or your child would like to participate in this event as a Participant, please complete the following form.

(If you are under 18, please have your parent or guardian complete the form.)
Personal Information

Location:
*Participant's First Name:
*Participant's Last Name:
Gender:
*Parent/Guardian Name:
*Address:
*City:
*State:
*Zip:
Primary Phone:
(555-555-5555)
Cell Phone:
(555-555-5555)
Email:
*Birthday:
(MM/DD/YYYY)
*Last Grade Completed:
Allergies, Medical, & Special Needs:
(Leave Blank if None)
*Emergency Contact Name (1):
*Emergency Contact Phone (1):
(555-555-5555)
Emergency Contact Name (2):
Emergency Contact Phone (2):
(555-555-5555)
*Authorized Pickup #1:
Authorized Pickup #2:
Do you attend Church?
If so, where?
May we have permission to photograph your child?
May we have permission to use your child's photograph in church publications?
Comments: