KidZone Wednesday's Registration

Ages 3yrs - 5th Grade
Program runs Sept. 18th - May 7th, 6:30pm - 8:15pm
Childcare provided for ages 3mo - 2yrs if you are attending a Wednesday Night Life Group

Mom Name

Dad Name

This address will receive a confirmation email

Mom Cell

Dad Cell

Address

Emergency Contact Name & Phone Number (NOT parent)

Are you attending a Bible Study on Wednesday Nights?

Yes No

Childs Name (first & last)

Birth Date

Allergies (if no allergies then please mark n/a)

Childs Name (first & last)

Birthdate

Allergies (if no allergies then please mark n/a)

Childs Name (first & last)

Birthdate

Allergies (if no allergies then please mark n/a)

Childs Name (first & last)

Birthdate

Allergies (if no allergies then please mark n/a)

Medical Release: In the event of an emergency, I understand that a reasonable effort will be made to contact me. If I cannot be reached, I hereby authorize a representative of Authentic Life Church to act on my behalf to seek emergency medical care or treatment for my child. I further give my permission to any physician or other qualified medical personnel to administer any and all emergency medical care which they deem necessary.

Parent Signature

Video/Photo Release: I give permission for images of my child, captured during Kid Zone Wednesdays through video, photo and digital camera, to be used by ALC in promotional materials and publications.

Parent Signature

KidZone Wednesday's Registration

Description

Please Fix the Following