Parkside Primary School Good News Club Registration Form

Child's Information

Sponsored by: Child Evangelism Fellowship of IL, Inc.

Conducted by: Hearts Harvest Church

Contact: Brad Herzberg (618)980-0090

Start Time: 3:00 PM
End Time: 4:30 PM

Date: Every Thursday September 4 - December 4—only on full days of school
Location: Parkside Primary School

Who can attend? All boys and girls, grades K-5th, regardless of religious background. Parents are also welcome to attend with child.

This is not an activity of the school or the school district.

Child's Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade*

#2 Child's Name

First NameLast Name

Birth Date

MonthDayYear

Grade

#3 Child's Name

First NameLast Name

Birth Date

MonthDayYear

Grade

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Parent's Name*

First NameLast Name

Home Number

Cell Number*

E-mail*

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship

Phone Number*

Alt. Phone Number

Does your child/children have any allergies, chronic illness, or medical conditions? If yes, please describe.

List names of people who are authorized to pick up your child.

I hereby assign and grant to Child Evangelism Fellowship Inc., the ownership, use and proceeds of all photographs or video of my minor child for advertising, educational and promotional purposes.*

YesNo

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature