*Participant's First Name: |
__________________________________ |
*Participant's Last Name: |
__________________________________ |
*Parent/Guardian Name: |
__________________________________ |
*Address: |
__________________________________ |
*City: |
__________________________________ |
*State: |
__________________________________ |
*Zip: |
__________________________________ |
*Home Phone: |
(______)______-________ |
Work Phone: |
(______)______-________ |
Cell Phone: |
(______)______-________ |
Email: |
__________________________________ |
*Birthday: |
__________________________________ |
*Last Grade Completed: |
__________________________________ |
Allergies, Medical, & Special Needs: |
|
*Emergency Contact Name (1): |
__________________________________ |
*Emergency Contact Phone (1): |
(______)______-________ |
Emergency Contact Name (2): |
__________________________________ |
Emergency Contact Phone (2): |
(______)______-________ |
*Authorized Pickup #1: |
__________________________________ |
Authorized Pickup #2: |
__________________________________ |
Are you a member of this church?: |
Yes No (circle one) |
Guest of: |
__________________________________ |
Do you attend Church?: |
Yes No (circle one) |
If so, where?: |
__________________________________ |
*May we have permission to photograph your child?: |
Y N (circle one) |
*Use Photograph: |
Y N (circle one) |
Would you like to purchase a T-Shirt?: |
Y (circle one) |
T-Shirt Size: |
__________________________________ |
Will you be attending Family Night on Thursday, June 13th from 6:00-8:00?: |
Y (circle one) |
*Family Night Attendance: |
__________________________________ |
Comments: |
|
Gender: |
Male Female (circle one) |