| *Participant's First Name: |
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| *Participant's Last Name: |
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| Gender: |
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| *Parent/Guardian Name: |
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| *Address: |
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| *City: |
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| *State: |
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| *Zip: |
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*Primary Phone:
(555-555-5555) |
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Work Phone:
(555-555-5555) |
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| Email: |
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*Birthday:
(MM/DD/YYYY) |
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| *Current Grade: |
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Allergies, Medical, & Special Needs:
(Leave Blank if None) |
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| *Emergency Contact Name (1): |
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*Emergency Contact Phone (1):
(555-555-5555) |
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| Emergency Contact Name (2): |
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Emergency Contact Phone (2):
(555-555-5555) |
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| *Authorized Pickup #1: |
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| Authorized Pickup #2: |
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| Authorized Pickup #3: |
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Need a ride?:
(Check this box to request pickup/dropoff service.) |
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| If so, where?: |
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| Are you a member of this church? |
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| Guest of: |
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| Do you attend Church? |
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| If so, where? |
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| May we have permission to photograph your child? |
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| May we have permission to use your child's photograph in church publications? |
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| Comments: |
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| *Choose the days that your child will attend: |
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