RTC & GNC Registration Form

RTC or GNC Student Registration Form

Fill out the form carefully for registration
Which option would you like to sign up for?*

Dingman Delaware Primary Afterschool Good News Club on MondaysDingman Delaware Elementary Afterschool Good News Club on MondaysEvergreen Elementary Released Time Class on MondaysWallenpaupack South Elementary Afterschool Good News Club on TuesdaysDelaware Valley Elementary Afterschool Good News Club on WednesdaysRD Wilson Released Time Class on ThursdaysWallenpaupack North Released Time Class on ThursdaysShohola Afterschool Good News Club on ThursdaysStourbridge Released Time Class on ThursdaysLakeside Afterschool Good News Club on Fridays

attending students #
How many students are attending?*

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Student #1
Student Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Age*
Attending School*
Teacher's Name
What grade is the student currently in?
Medications or Food Allergies*

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Student #2
Student Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Age*
Attending School*
Teacher's Name
What grade is the student currently in?
Medications or Food Allergies*

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Student #3
Student Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Age*
Attending School*
Teacher's Name
What grade is the student currently in?
Medications or Food Allergies*

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Student #4
Student Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Age*
Attending School*
Teacher's Name
What grade is the student currently in?
Medications or Food Allergies*

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Student #5
Student Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Age*
Attending School*
Teacher's Name
What grade is the student currently in?
Medications or Food Allergies*

stopper#6

Student #6
Student Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Age*
Attending School*
Teacher's Name
What grade is the student currently in?
Medications or Food Allergies*

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Student #7
Student Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Age*
Attending School*
Teacher's Name
What grade is the student currently in?
Medications or Food Allergies*

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Parent Info
Parent/ Guardian Full Name*

First NameLast Name
Relationship to student(s)*
Parent/Guardian Full Name

First NameLast Name
Relationship to student(s)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent E-mail
example@example.com
Mobile Number*
Home Number
Emergency Number*
Church you attend
If you do not attend a church, please select None.

I give my permission for my child to be included in photographs to be used in the promotion of Wayne-Pike Child Evangelism Fellowship, Inc. via monthly newsletter, Wayne-Pike CEF Website & Facebook page.

YesNo
With my signature, I, {parentGuardian} hereby request that my child, {studentName}, {studentName139}, {studentName145}, attends {whichOption} hosted by Wayne - Pike Child Evangelism Fellowship.

Clear

Please make note the following information before you submit this application.

I, {parentGuardian} hereby request that my child, {studentName}, {studentName139}, {studentName145}, attends {whichOption} hosted by Wayne - Pike Child Evangelism Fellowship.

If your child will not be attending Good News Club or Released Time Class on that day, please notify your school officials.

Office contact info:
Phone: 570 – 253 – 6444
Mailing: PO Box 628 Honesdale, PA 18431
Email: wpcef1@gmail.com

Important Program Information
Should be Empty: