PCC Community Kids Afterschool till 530pm - Kindergarten - 8th Grade

Perrin Community Church

Community Kids - Afterschool till 5:30p
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Child's Age*
Kindergarten1st2nd3rd4th5th6th7th8th
MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*
Format: (000) 000-0000.
Please list anything we should know about your child.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: