Breaker Rock Beach
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
*Participant's First Name:
*Participant's Last Name:
*Preferred Name for Name Tag:
*Grade Completed June 2024:
*Parent/Guardian Name:
*Address:
*City:
*State:
*Zip:
Primary Phone:
(555-555-5555)
Work Phone:
(555-555-5555)
Cell Phone:
(555-555-5555)
Email:
*Birthday:
(MM/DD/YYYY)
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:
Are you a member of this church?
Guest of:
Do you attend Church?
If so, where?
*Photograph Permission:
(Do you give First Norfolk permission to take photographs of your child to use for church publication and social media.)
Comments:
Gender:
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