THE WELL YOUTH: AFTER DARK
Walker Pentecostal Church | 9969 Florida Blvd.
Saturday, August 15th - 6:30PM
Ages: 12+
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
PARENT / GUARDIAN INFORMATION
Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
EMERGENCY INFORMATION
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Allergies or Medical Concerns
*
PICKUP / RELEASE
My child may leave:
*
Only with parent/guardian
With approved adult listed below
May sign themselves out
Approved Adult(s) for Pickup
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Permission and Release:
I give permission for my child to participate in “The Well Youth: After Dark” at Walker Pentecostal Church. I understand that games and activities will take place during the event, and I release Walker Pentecostal Church, its pastors, leaders, and volunteers from liability in the event of accidental injury. I also give permission for photos and/or videos of my child taken during the event to be used for church, ministry, website, and social media purposes.
*
I agree
Submit
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