5-Day Club Registration
July 14th-18th 1:30-3:30pm King's Grace Fellowship 48 W 18th Ave Junction City, OR 97448
Participant's Name
*
First Name
Last Name
Birth Date
*
Please select a month
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Month
Please select a day
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Day
Please select a year
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Year
Desired Name Tag
Please provide any medical or dietary restrictions you have
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Family Information
Parent/Guardian's Name
*
First Name
Last Name
Contact Phone Number
*
E-mail Address
example@example.com
If anyone OTHER THAN THE PARENT will be picking up, please fill out this portion
Alternative Pick Up Person
First Name
Last Name
Relationship to Participant
Alternative Pick Up Person
First Name
Last Name
Relationship to Participant
Submit Form
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