*Participant's First Name: |
__________________________________ |
*Participant's Last Name: |
__________________________________ |
*Parent/Guardian Name: |
__________________________________ |
*Address: |
__________________________________ |
*City: |
__________________________________ |
*State: |
__________________________________ |
*Zip: |
__________________________________ |
*Home Phone: |
(______)______-________ |
Work Phone: |
(______)______-________ |
*Cell Phone: |
(______)______-________ |
*Email: |
__________________________________ |
*Birthday: |
__________________________________ |
*Pick a grade: |
__________________________________ |
*Is your child allergic to hand sanitizer?: |
Yes No (circle one) |
Allergies, Medical, & Special Needs: |
|
*Permission to Treat: |
Y N (circle one) |
*I am the/a parent and/or legal guardian of the child I am enrolling. I understand it is my responsibility to notify the classroom leaders as to where I can be reached in the event of an emergency.: |
I understand. (circle one) |
Important information you think we should know about your child:: |
|
*Emergency Contact Name (1): |
__________________________________ |
*Emergency Contact Phone (1): |
(______)______-________ |
*Emergency Contact Name (2): |
__________________________________ |
*Emergency Contact Phone (2): |
(______)______-________ |
Custody Concerns?: |
|
*Authorized Pickup #1: |
__________________________________ |
Authorized Pickup #2: |
__________________________________ |
Authorized Pickup #3: |
__________________________________ |
Authorized Pickup #4: |
__________________________________ |
*Does your child need a ride?: |
Yes No (circle one) |
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?: |
Yes No (circle one) |
May we have permission to use your child's photograph in church publications?: |
Yes No (circle one) |
Select a t-shirt size: |
__________________________________ |
Comments: |
|
Gender: |
Male Female (circle one) |