JYC Registration Form

JYC Registration Form
Student Information
Student Name*
Gender*

MaleFemale
Birthdate*

MonthDayYear
Date
Age*
Address*
Apt. #
City*
State*
Zip*
Does the child have a parent in the military?

YesNo
School*
Homeroom teacher*
Grade*
Parent/Guardian Information
Parent/Guardian*
Parent Email*
example@example.com
Home phone*
Dad's Work/Cell Phone
Please enter a valid phone number.
Mom's Work/Cell Phone
Please enter a valid phone number.
Emergency Contact Person*
Phone*
Emergency Contact Person
Phone
Child's allergies (peanuts, chocolate, etc)*
Church
Pastor
Student Pickup

These people (including phone numbers) are allowed to pick up my child if I'm not able:
Person who can pick up student
Phone
Person who can pick up student
Phone
Person who can pick up student
Phone
My child is allowed to attend the JYC club every Monday after school until 4:00 P.M. (There will be no clubs when school is released early and on school holidays) My child has permission to ride the church van to be transported to the club meeting. I understand it is my responsibility to pick up my child atCalvary Baptist Church, 2000 Broad Ave. at 4:00 P.M. (unless I have checked below that they will be walking home), and failure to do so will jeopardize my child's continued participation.
Parent /Guardian Signature*

Clear
Date*

MonthDayYear
Date
Check here to show how your child will get home on club day.*

My child will be picked up.My child will walk home.
Should be Empty:

Student Information