5-Day Club Registration
Child's Name
*
First Name
Last Name
Gender
*
Male
Female
Age
*
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Grade Next Year
*
Select Grade Next Year
Pre-K
K
1st
2nd
3rd
4th
5th
6th
7th
8th
School Attending Next Year
*
Primary Email
*
example@example.com
Primary Phone Number
*
Church
If currently attending one
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
5-Day Club that above named child would like to attend when it is scheduled
*
Alsea Christian Fellowship 5-Day Club - July 13-17; 9am-12pm
Southside Youth Center 5-Day Club - Aug 3-7; 10am-12 noon
Shepherd of the Valley Church 5-Day Club - Aug 17-21; 10am-12 noon
If someone besides the main guardian is dropping off or picking up the child, please list their name and contact info below:
Any Additional Notes/Food Allergies
Guardian's Full Name
*
“I, the parent (or guardian) of the above named child, do hereby give permission for them to attend 5-Day Club at the chosen location. I release Child Evangelism Fellowship and the facilities used from liability for any injuries or sickness incurred as a result of my child’s participation in 5-Day Club. I hereby assign and grant to Child Evangelism Fellowship full use of all photographs of the above named child, without reservation or limitation, including use of photographs for promotional purposes.”
Guardian's Signature
*
(NOTE: On electronic forms, your typed signature has the same effect as your written signature.)
Submit
Should be Empty: