ADVENTURE CLUB REGISTRATION 2016-17
Register as a family. * = Required
Parent(s)/Caregiver First Name:
*
Last Name:
*
Street Address:
*
City:
*
Zip Code:
*
Phone:
*
Email:
*
Emergency contact name during Adventure Club: (Name, Relationship, Phone):
*
Child 1 First Name:
*
Last Name:
*
Birthdate:
*
Age
*
*
Male
Female
Grade in school 2016-17:
*
Allergies/Special Needs
Child 2 First Name:
Last Name:
Birthdate:
Age
Male
Female
Grade in school 2016-17:
Allergies/Special Needs
Child 3 First Name:
Last Name:
Birthdate:
Age
Male
Female
Grade in school 2016-17:
Allergies/Special Needs
Do you have a home church?
Yes
No
If Yes, name of your church:
Parents:
Do you plan to attend
as often as I can
frequently
occasionally
The cost of $30 per child to be paid at your first attendance.
Security Code
*