Please complete the following information:

Family Information

Last Name: Primary Phone:
Email: Address:

Parent 1 Name: Cell Phone:
Other Email Address:

Parent 2 Name: Cell Phone:
Other Email Address:

 


Children Information

Child Name: Preferred Name:
     Gender: MF Birthdate:    Grade:
    Child lives with:
    Allergies? YesNo If Yes, please describe:


Child Name: Preferred Name:
     Gender: MF Birthdate:    Grade:
    Child lives with:
    Allergies? YesNo If Yes, please describe:


Child Name: Preferred Name:
     Gender: MF Birthdate:    Grade:
    Child lives with:
    Allergies? YesNo If Yes, please describe:


Child Name: Preferred Name:
     Gender: MF Birthdate:    Grade:
    Child lives with:
    Allergies? YesNo If Yes, please describe:


Child Name: Preferred Name:
     Gender: MF Birthdate:    Grade:
    Child lives with:
    Allergies? YesNo If Yes, please describe:


Please let us know of anyone who is not authorized to pick up your child(ren):

Please give us emergency contact information (other than the parent):
    Name: Relationship:
Phone Number:

PUBLICITY RELEASE: I give permission for First Presbyterian Church to use photograph and/or video image(s) of my child(ren) named on this registration form for in house and/or public publicity such as but not limited to brochures, newsletters, emails, church website and social media such as Facebook. YesNo