Wonderful Wednesday Registration

                             

2011 - 2012 WONDERFUL WEDNESDAY REGISTRATION FORM
Full Name:
 * required
   
 Address:
Father's Name:
 * required
Mother's Name:
 * required
Home Phone:
 * required
Work Phone:
 * required
Cell Phone:
 * required
E-mail Address:
 * required
BIOGRAPHICAL INFORMATION:
Date of Birth:
 * required
   
Age:
 * required
Current Grade:
 * required
Gender:
 * required
Home Church:
School:
Teacher:
Allergies/Medical Information/Other:
 * required
Special Dietary Requirements:
 * required
Pictures May Be Taken of My Child For Promotional Material:
 * required
INSURANCE INFORMATION:
Insurance Company:
 * required
Policy/Group #:
 * required
 

 PLEASE PROVIDE A COPY OF YOUR INSURANCE CARD AT CHECK-IN

In the event of an accident and I am unable to be reached, I grant permission for an adult staff member(s) to seek and/or obtain medical assitance that may be necessary.
Parent Signature:
 * required
EMERGENCY CONTACT INFORMATION:
Emergency Contact:
 * required
Relationship:
 * required
Home Phone:
 * required
PICK UP PROCEDURE:
Please list individuals (and relationship) who have perimission to pick up your child each week.
Children only released to individuals listed here, unless otherwise notified by the parent/guardian.
Individuals with Permission to Pick Up:
 * required