Email

Address

City

State

Zip

Home Phone

Mobile Phone

If yes, name of church

Emergency Contact 1

Phone

Relationship to Child

Emergency Contact 2

Phone

Relationship to Child

Name of Child #1

Age

Grade

Birthday

Child’s T-shirt Size

Allergies (state none if none) or Special Information (Medications, activity restrictions):

Name of Child #2

Age

Grade

Birthday

Child’s T-shirt Size

Allergies (state none if none) or Special Information (Medications, activity restrictions):

Name of Child #3

Age

Grade

Birthday

Child’s T-shirt Size

Allergies (state none if none) or Special Information (Medications, activity restrictions):

Name of Child #4

Age

Grade

Child’s T-shirt Size

Birthday

Allergies (state none if none) or Special Information (Medications, activity restrictions):

Name

Relationship to Child

Name

Relationship to Child

Name

Relationship to Child

Name

Relationship to Child

Printed Name

Date

Centenary Church

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Parent/Legal Guardian Information

Emergency Contact (Other than parent)

Child Information

Approved Pick-Up List