2019 Wednesday Night Clubs Registration
(Begins September 18 for ages 3-5th grade)
Child's Name
*
Age
*
Grade
*
Child's Name
Age
Grade
Child's Name
Age
Grade
Child's Name
Age
Grade
Parent's Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home E-mail Address
Home Phone Number
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Emergency Contact:
Name
Phone Number
-
Area Code
Phone Number
Who may pick up children:
Name
Phone Number
-
Area Code
Phone Number
Who may pick up children:
Name
Phone Number
-
Area Code
Phone Number
Who may pick up children:
Name
Phone Number
-
Area Code
Phone Number
Allergies or other medical conditions:
*
I understand that pictures and/or videos may be taken of my child during this event. These photos may be used on the church webpage, publications or social media. No names of children will be used. For further clarification please contact the church office at 267-3373.
*
I understand and agree
Submit
Should be Empty: