First Name

Last Name

Male
Female

Home Address

City State Zip

Home Phone (numbers only)

Alternate Phone(numbers only)

School Grade Completed Birthdate MMDDYY

ATTENTION! Your child must have turned 4 by 9/1/04 to participate!

Allergies or Special Needs

Parent or Guardian Name

Does Your Child Attend Sunday School?

Yes
No

If Yes, where?

Emergency Contact:

Name

Relationship

Phone

Persons Authorized to pick up your child