Today’s Date:

____________________

Please fill out this card completely so that your child’s name and
information can be put into our Database. (PLEASE PRINT!!!)

Name: _____________________________________________
First Middle Last

Street Address: ______________________________________

City: _______________________ Zip: ____________________

Home Phone: __________________ Birthdate: ______________

Cell Phone: __________________Small Group: _____ Age: _____

Email: _______________________ Male: ______ Female: _____

School: _____________________________________________

Any medical problems, food or life-threatening allergies of which we

should be aware?

___________________________________________________

Parents’ Information (REQUIRED):

Father’s Name: _________________ Cell Phone: _____________

Email Address: ___________________________________

Mother’s Name: _________________ Cell Phone:_____________

Email Address: ___________________________________