Child's Name

Your email

Your Phone Number

Age/Grade Completed
—Please choose an option—4 yrs5 yrs (not yet Kindergarten)Kindergarten1st2nd3rd4th5th/6th

Food Allergies

Medical Conditions

Permission to be photographed:
yesno

Parent(s) Name(s):

Street Address:

City:

Zip Code:

Church you attend:

Emergency Contact Name:

Emergency Contact Phone Number:

Authorized Pick-Up: (Other than parent)

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