Midweek Program for Kids & Youth
Wayside Presbyterian Church | 600 Stony Battery Road | Landisville PA 17551
Children & Youth
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Information
Mother/Guardian
First Name
Last Name
Cell Number
Father/Guardian
First Name
Last Name
Cell Number
Family Email checked most frequently
example@example.com
Home Number
Emergency Information
Emergency Contact's Name
First Name
Last Name
Relationship
Please Select
Mother
Father
Grandparent
Aunt
Uncle
Sibling
Babysitter/Nanny
Other
Phone Number
Photo Release
Wayside will occasionally take pictures or video of the children during our programs. Photos may be displayed inside the church, in slides/videos, on our website, our Facebook page, brochures and the local newspaper. Names of the children will never be used with their pictures. Permission to use images of my children as described.
Please Select
Yes
No
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
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