Please return this form directly to the church office.
No child may participate in the church's education program without having first been registered.

1. NAME_______________________________________________

AGE_____ DATE OF BIRTH____________GRADE IN AUGUST_____

2. NAME_______________________________________________

AGE_____DATE OF BIRTH__________ GRADE IN AUGUST___

ADDRESS____________________________________________________

______________________________________________ZIP__________

PLEASE INDICATE ANY ALLERGIES OR ANY SPECIAL PHYSICAL OR DIETARY NEEDS

____________________________________________________________

_____________________________________________________________

_______________________________________

Parent/ Guardian/Responsible adult______________________________

_____________________________________________________________

Address (if different from above)_______________________________

________________________________________________

Telephone___________________

Second telephone in case of emergency____________________

Email______________________________________________