Parent/Guardian Name

Address

Phone Number    Work Number   E-mail address

If your child presently attends a church, name of the church

Emergency Contact:    Phone

Child's Name

Date of Birth      Grade completed this Spring

Allergies or Other Concerns

Child's Name

Date of Birth        Grade completed this Spring

Allergies or Other Concerns

Child's Name

Date of Birth        Grade completed this Spring

Allergies or Other Concerns

Please check if your child/children need transportation provided.