Fields marked with (*) are required
(1) Parent/Guardian Full Name
*
(2) Parent/Guardian Full Name
Address
*
City
*
State
*
- -
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
*
E-mail Address
Phone (1)
*
Home
Cell
Work
Phone (2)
Home
Cell
Work
Phone (3)
Home
Cell
Work
Child 1
First Name
*
Last Name
*
Gender
*
Male
Female
Birthdate
*
- - Choose One - -
January
February
March
April
May
June
July
August
September
October
November
December
*
- - Choose One - -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
*
-year-
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
Age
*
-
3
4
5
6
7
8
9
10
11
12
Grade entering in fall 2011
*
4
5
6
Specific Needs (allergies, special needs, etc.)
Child 2
First Name
Last Name
Gender
Male
Female
Birthdate
- - Choose One - -
January
February
March
April
May
June
July
August
September
October
November
December
- - Choose One - -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
-year-
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
Age
-
3
4
5
6
7
8
9
10
11
12
Grade entering in fall 2011
4
5
6
Specific Needs (allergies, special needs, etc.)
Parents are welcome to join us for laser tag, cost is $10 per parent.
Parents Attending Laser Tag
Release Form
I give permission for my child(ren) to ride in a carpool or on the Jamul Community Church bus for the purpose of attending off-site events (Laser tag) during Gravity on August 20, 2011.
Please enter your name here to sign this release*