Child Registration

Child's Name

First NameLast Name

Child's Age

Child's Birthday

Date

Current Grade

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are there any food allergies and/or physical/medical conditions that we should be aware of?

Parent/Guardian 1 Name

First NameLast Name

Parent/Guardian 1 Phone

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian 1 Email

example@example.com

Parent/Guardian 2 Name

First NameLast Name

Parent/Guardian 2 Phone

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian 2 Email

example@example.com

One of our volunteers will text you should we need assistance with your child during service. If you have a preference for who we should text let us know in the box below.

Address if different than Child's

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact (Parents will be contacted first)

First NameLast Name

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

I First Name* Last Name* , the parent or legal guardian of Child's First Name* Last Name* DO DO NOT* grant First Presbyterian Church, Wichita, KS my permission to use photographs of my child for any legal use, including but not limited to: publicity, copyright purposes, illustration, advertising and web content.
Furthermore, I understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

Parent/Guardian Signature

Photo Release