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PLEASE MAKE A COPY OF THIS FORM ON A SEPARATE SHEET, AND COMPLETE THE FORM ON THAT SHEET. WHEN FINISHED, EMAIL TO: BRIANJALVERSON@GMAIL.COM

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Child’s name _____________________________________________________________________________________________________________________
 

Gender: Male _____ Female _____ Birthdate _______/_______/_______ Grade completed ________________________________
 

Address ____________________________________________________ City ____________________________ State ________ Zip _______________
 

Parent/Guardian _____________________________________________________________________________________________________________________
 

Phone __________________________________________________ Email ___________________________________________________________________
 

Emergency contact ______________________________________________________________________________________________________________
 

Relationship to child ______________________________________________________ Phone ______________________________________________
 

Who can pick up your child?______________________________________________________________________________________________________
 

Name of home church __________________________________________________________________________________________________________
 

Food allergies Y_____ N_____ List ________________________________________________________________________________________________
 

Medical concerns Y___ N___ Explain ____________________________________________________________________________________________

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