Name of your Child
First Name
Last Name
Age
Gender
Male
Female
Grade Level
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home/Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Church affiliation
Is he/she carrying an Epi-pen?
Yes
No
Does your child have any allergies?
Yes
No
If so, what are the allergies of your child?
Does your child have any medical condition that we should be aware of?
Yes
No
If so, what is this medical condition? Please elaborate below:
Pick Up Authorization
Authorized person(s) to pickup your child after the Family Fun Day
Full Name 1
First Name
Last Name
Relationship
Emergency Contact Information
At least one needed, please
Emergency Contact 1
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Would it be okay if we take photos and videos of your child during our Fun Day which will be posted on our social media account?
Yes
No
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: