Kids Club: Participant Registration 2021

for Age 3 - Grade 5

Wednesday Nights
6:30 - 8:00pm
Sept 29, 2021 - May 11, 2022

Please fill out a separate registration form for each family.
This will enable us to have the correct parent/guardian & contact info for each child. Thank you!
Today's Date

Month Day Year
General Information
Number of Children Registering *

Parent/Guardian Section
Parent/Guardian Info:
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone *
Work Phone
Cell Phone
E-mail *
How would you like to volunteer? *
Medical/Allergy/Emergency Contact Information
Medical Conditions:
Any medical conditions about your child that will help us should an emergency occur.
Known Allergies:
Any known allergies that your child has that will help direct us in making decisions for your child.
Behavior Concerns:
Any behavioral conditions about your child that will be helpful to us.
Many times we have the opportunity to take pictures of children at our Wednesday evening Bible program and try to capture the fun moments of theme nights and the activities they participate in on Wednesday evenings. These photographs may be used for flyers, church publications, our end of the year celebration movie, or our Kids Crossing Children's Ministry / Ebenezer BFC Facebook page. Individual names will not be associated with any picture taken. We will not tag your child on Facebook. *

Yes, I give permission for my child's picture to be used No, I do not want my child included in any pictures
Emergency Contact: Same as Parent/Guardian?

Yes
Emergency Contact Name #1: *

First Name Last Name Relationship
Emergenct Contact Phone #1: *
Emergency Contact Name #2:

First Name Last Name Relationship
Emergenct Contact Phone #2:
Dismissal: Who can pick up your child(ren)?
Pick-up person on site?

Yes
Same as Parent/Guardian?

Yes
Authorized Pickup #1 *

First Name Last Name Relationship
Authorized Pickup #2

First Name Last Name Relationship
Authorized Pickup #3

First Name Last Name Relationship
Authorized Pickup #4

First Name Last Name Relationship
Church Affiliation
Church Member Status:
Church Affiliation:
Name of Church You Attend (if any)
Guest Of:

First Name Last Name
Comments/Questions
Should be Empty: