5-Day Club Registration

Monday, July 21st - Friday, July 25th
10:00 am - 12:00 pm
For Ages 5 to 12

Child's Name

First Name

Last Name

Gender

Child' #1 Date of Birth

YYYY

Child #2 Name

First Name

Last Name

Gender Child #2

Child #2 Date of Birth

YYYY

Child #3 Name

First Name

Last Name

Gender Child #3

Child #3 Date of Birth

YYYY

Child #4 Name

First Name

Last Name

Gender Child #4

Child # 4 Date of Birth

YYYY

Parent/Guardian Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Number(s)

(###)

###

####

Emergency Contact #1

First Name

Last Name

Phone Number #1

(###)

###

####

Emergency Contact #2

First Name

Last Name

Phone Number #2

(###)

###

####

Medical Information

Medical or other information we need to know. (Please include any food allergies.)

Dismissal Information

Who may pick up your child at the end of each day?

Guest Information

If your child is visiting our church, who is (s)he a guest of?

First Name

Last Name

How did you hear about the 5-Day Club?

Checkbox

By completing this registration I agree that my child has permission to attend the 5-Day Club and that they or myself may be photographed and that, any photos may be used for both internal and external promotion purposes.

I understand and agree