| Note: ONLINE REGISTRATION OFFICIALLY CLOSED ON 6/12/2022. Walk-in registrations will be allowed on Monday, June 20 when doors open at 8:45 a.m. if space allows.
As of 6/3/2022, our PK/K has reached capacity and is closed for registration. |
| *Participant's First Name: |
__________________________________ |
| *Participant's Last Name: |
__________________________________ |
| *Parent/Guardian Name: |
__________________________________ |
| *Address: |
__________________________________ |
| *City: |
__________________________________ |
| *State: |
__________________________________ |
| *Zip: |
__________________________________ |
| *Cell Phone: |
(______)______-________ |
| *Email: |
__________________________________ |
| *Birthday: |
__________________________________ |
| *Grade in fall of 2022: |
__________________________________ |
| *T-Shirt Size: |
__________________________________ |
| *Gender: |
Male Female (circle one) |
| *Church attendance: |
Yes
No (circle one) |
| Church Name: |
|
| Allergies, Medical & Special Needs: |
|
| *Health Insurance Company: |
|
| *Insurance Policy Number: |
|
| *Physician's Name: |
|
| *Physician's Phone Number: |
(______)______-________ |
| *Medical authorization in case of an emergency: |
Yes
No (circle one) |
| *Emergency Contact Name (1): |
__________________________________ |
| *Emergency Contact Phone (1): |
(______)______-________ |
| *Authorized Pickup #1: |
__________________________________ |
| Authorized Pickup #2: |
__________________________________ |
| Comments: |
|
