| *Preferred Name for Name Tag: |
|
| *Participant's First Name: |
|
| *Participant's Last Name: |
|
*Birthday:
(MM/DD/YYYY) |
|
| *Gender: |
|
| *Last Grade Completed: |
|
| *Parent/Guardian Name: |
|
| *Address: |
|
| *City: |
|
| *State: |
|
| *Zip: |
|
*Cell Phone:
(555-555-5555) |
|
Home Phone:
(555-555-5555) |
|
Work Phone:
(555-555-5555) |
|
| *Email: |
|
| Do you attend Church? |
|
| If so, where? |
|
| Are you a member of this church? |
|
*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: |
|
| Authorized Pickup #3: |
|
| Authorized Pickup #4: |
|
| Guest of: |
|
| May we have permission to photograph your child? |
|
| May we have permission to use your child's photograph in church publications? |
|
| Comments: |
|
| *Choose the days that your child will attend: |
|