*Participant's First Name: |
__________________________________ |
*Participant's Last Name: |
__________________________________ |
Gender: |
Male Female (circle one) |
*Parent/Guardian Name: |
__________________________________ |
*Address: |
__________________________________ |
*City: |
__________________________________ |
*State: |
__________________________________ |
*Zip: |
__________________________________ |
Home 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: |
__________________________________ |
*OHBC Church Member: |
Y N (circle one) |
Guest of: |
__________________________________ |
*Do You Attend Church?: |
Y N (circle one) |
If so, where?: |
__________________________________ |
Photography: |
|
Comments: |
|
*Preferred Name for Name Tag: |
__________________________________ |