Registration Form

Child's Name:

Child's Age:

Date of Birth

Last School Grade Completed:

Name of Parent(s)

Street Address:

City:

State:

Zip:

Home Telephone:

Parent/Caregiver's Cellphone

Home Email Address:

Home Church

Social Media Permission: Social Media Permission: Yes, my child's picture can be used on social media No, my child's picture can not be used on social media

Emergency Contact:

Phone:

Relationship to Child: