Registration Form

Registration FormHeather Williams2025-04-07T21:16:37-05:00

Child Info

Childs Full Name: Birthdate: Sex: Childs Address:

Name: Email: Home Phone: Work Phone: Cell Phone: Workplace & Hours:

Name: Email: Home Phone: Work Phone: Cell Phone: Workplace & Hours:

Contact 1: Phone 1: Contact 2: Phone 2:

Do you attend church? Church Name:

Summer School Year Days Attending:
Monday Wednesday Drop-In Extended Care:

Doctor & Phone: Health Plan: Immunizations Up to Date? Yes No Health Problems: Special Needs: Allergies: Medications:

Use of first aid Pain relievers Stomach remedies ER consent Exceptions:

Yes No Exceptions:

Classroom Only Social Media Marketing No Photos

Parent/Guardian Signature: