Wednesday Night Student Registration
Student Name(1)
*
First Name
Last Name
Age
Student Name(2)
First Name
Last Name
Age
Student Name(3)
First Name
Last Name
Age
Student Name(4)
First Name
Last Name
Age
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Parent/Guardian Name
*
Parent/Guardian Phone
*
Format: (000) 000-0000.
Emergency Contact
*
Emergency Contact Phone
*
Format: (000) 000-0000.
Food Allergies
Is there anything we should know about?
I understand that I will be notified in the case of a medical emergency involving my child. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child. I agree to notify the church in writing in the event of any health or transportation changes, which would restrict my child’s participation in any normal children’s or youth activities. I understand that Leon Assembly of God will NOT be held responsible for any injuries or health emergencies that occur during church activities.
*
YES
NO
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