SOUTH PINE ACADEMY GNC REGISTRATION

PARENT / GUARDIAN INFORMATION
Parent/Guardian Full Name*
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Home Address*

Street Address.

Street Address Line 2

CityState

Zip CodeCountry
Emergency Contact Name*
Full Name
Emergency Contact Number*
Please enter a valid phone number.
Alternate Pick Up 1 (This person is permitted to pick up my child)

Full NameContact Number
Alternate Pick Up 2 (This person is permitted to pick up my child)

Full NameContact Number

PERMISSION TO ATTEND GOOD NEWS CLUB
My children, listed on this form, have permission to attend the Good News Club after school club.*

YESNO
Photography and Video Release: Child Evangelism Fellowship® may, from time to time, document the activities of the ministry with photos or videos. I hereby assign and grant to Child Evangelism Fellowship Inc., its subsidiaries and successors, and assign the unqualified right to the ownership, use and proceeds of all photographs or video of me or my minor child, without reservation or limitation, including use of photographs or video of me or my minor child for, but not limited to, advertising, educational and promotional purposes.

YESNO
Signature*

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SOUTH PINE ACADEMY