Name Birthday ______ Last Grade Completed______Age___

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Name __________________________________________________________________ Birthday ___________ Last Grade Completed______Age________Gender __________ Parent/Guardian Name _____________________________________________________ Address_______________________________City_________________Zip___________ Home Phone_________________________ Cell Phone___________________________ Email _________________________________________________________________ Allergies, Medical or Special Needs (ADHD, Autism,Sensory,etc) _______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Emergency Contact Name__________________________________________Phone___________________ Authorized Pickup Please list anyone who will be picking up your child other than parents ________________________________________________________________________ ________________________________________________________________________ Photo Release My child’s photo may be used in church publications and on media sites. Names will never be posted with out written consent. Agree____________ Disagree_____________ Parent’s Signature_________________________________________________________