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Little Flower's Girl Club Registration
Child's Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the child have any allergies?
Does the child have any medical conditions that we should be aware of?
Parent/Guardian Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Acknowledgment
I agree to follow the guidelines, rules, and policies of the organization.
I allow my child to be photographed or be part of the video that will be used for marketing, promotion, and advertisements.
The repeated offense of the youth may result in suspension or expulsion.
Parent/Guardian registered in this form has legal custody over the child.
I allow my child to ride any vehicle that is related to the group's activities provided that there's an adult on board.
For medical emergencies, I allow the medical team of this organization to take care of my child.
I release this organization from any and all liability from accident or injury to the child during the organization related events.
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: