Registration form for Tadpoles, Clubhouse and Club 56 Programs

Registration Form for all children's fall programs

Please fill in the form below.
Student Name *

First Name Last Name
Phone Number *

- Area Code Phone Number
E-mail *

Address *

Birthdate *

- Month - Day Year
Grade (As of Fall 2017) *
PS, K, 1-6
Program *
Dad's Name/ Cell
Mom's Name/ Cell
Worship Service you attend or home church
Emergency Contact Name/Number *
Allergies or Medical Conditions *
List Names of all people authorized to pick up your child *
I would be willing to provide snacks for this program *

Yes No
I give permission for my child to participate in the Shady Grove Student Ministries programs and events through the coming year.

I hereby release Shady Grove United Methodist Church, its staff and sponsors from responsibility and liability for any injury or illness my student may sustain through activities. In the event of an emergency, I authorize an adult to practice under the laws of the state where the services are needed. I expect to be contacted as soon as possible. It is my responsibilty to update my emergency contact information provided above.
I have read and agree to the medical release above: *
Please initial here
Should be Empty:

Registration Form for all children's fall programs