Divorce Care for Kids

Children's Registration Form (Ages 5-12)
Section 1: Registration Information
Child's Name*
Age*
Birth Date*

MonthDayYear
Grade*
Child's Name
Age
Birth Date

MonthDayYear
Grade
Child's Name
Age
Birth Date

MonthDayYear
Grade
Child's Name
Age
Birth Date

MonthDayYear
Grade
Your Name*
Relationship to Child*

MomDadOther
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Your Primary Phone*

Area CodePhone Number
Your Secondary Phone

Area CodePhone Number
Your E-mail
How did your hear about DC4K?
Parents are:*

SeparatedDivorced
How long?
Registration Fee: $12.00 per child; which includes your child's DC4K Workbook and all 13 Sessions

* We want every child to be able to attend, and we understand finances can be very tight during this time. If you need help with the registration fee, just check the box below and the registration will be paid from our scholarship fund.
Payment Type:*

I will bring the fee to the first night of the programI have sent in payment to VCNW, 9165 Round Top Rd, Cincinnati, OH 45251Please cover my child(rens)'s registration fee from the scolarship fund
For more information or questions, please contact Scott Osterfeld at 513-385-4888; Ext 108 or via Email at scott@vcnw.org .

Section 2: Pick Up Authorization

If I am unable to pick up my child(ren), the following persons are authorized to do so. A photo-ID will be required.
1) Full Name*

First NameLast Name
Relationship to Child*
Street Address*
City*
State*
Zip Code*
Primary Phone #*

Area CodePhone Number
Secondary Phone #

Area CodePhone Number
For more information or questions, please contact Scott Osterfeld at 513-385-4888; Ext 108 or via Email at scott@vcnw.org .
2) Full Name

First NameLast Name
Relationship to Child
Street Address
City
State
Zip Code
Primary Phone #

Area CodePhone Number
Secondary Phone #

Area CodePhone Number
Section 3: Emergency Contact Information

In case of an emergency and I cannot be reached, please contact the following persons.
1) Full Name*

First NameLast Name
Relationship to Child*
Street Address*
City*
State*
Zip Code*
Primary Phone #*

Area CodePhone Number
Secondary Phone #

Area CodePhone Number
2) Full Name

First NameLast Name
Relationship to Child
Street Address
City
State
Zip Code
Primary Phone #

Area CodePhone Number
Secondary Phone #

Area CodePhone Number
Section 4: Consent and Release
I understand that Divorce Care for Kids (DC4K) is not a counseling service or therapy program, but a Biblically based, Christ-centered program to help children of divorce heal in a group setting.
Registant's signature to be obtained at first class
Date

Section 5: Special Needs Information
Are there any special learning accommodations we need to be aware of regarding your child in order to provide the best possible program for your child?*

YesNo
If Yes, please specify
Does your child have any allergies, especially food allergies?*

YesNo
If Yes, please specify
Are there any other issues or information regaring your child (i.e., Behavioral, Emotional, Physical) that you would like to share that would help us best meet your child's needs?*

YesNo
If Yes, please specify
_______________________________________________________________________________________________________________________________

* Indicates Respose Required Vineyard Church Northwest Effective 1/28/2011
Should be Empty:

Children's Registration Form (Ages 5-12)