Salt & Light Club
Registration Form
Student's Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Child's Grade
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Teacher's Name
*
School
*
Clements/Parsons
House Creek
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian E-mail
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Emergency Contact (Not Person Listed Above)
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
How will your child get home?
*
Parent/Guardian Pickup
Walk
After School Program
Parent/Guardian is a teacher, walk to my room
Do you attend a church?
*
Yes
No
If you attend a church, where?
Are there any medical or special needs we should be aware of?
May we use your child's photo for promotional purposes? (No name will be associated with pictures.)
*
Yes
No
I give my permission for my child, listed above, to attend the Salt & Light Club.
*
Signed permission must be on file to attend the Salt & Light Club. Children will be dismissed at 4:30pm and must be promptly picked up. No transportation will be provided at the end of club. SLC staff are not responsible for children before or after club meetings.
Submit
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