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Child's Information:

First Name:

Last Name:

Age: Entering Grade: Gender:

T-Shirt Size:

Street Address:

City:

State:

Zip Code:

Allergies and/or Medical Conditions:
Enter none below if this does not apply to your child.

What church do you regularly attend/are a member of?

If church other than Presbyterian Church, which one?:

Guardian's Information:

Contact Email Address:

1st Parent/Guardian Name:

Home Phone: Cell Phone: Work Phone:

2nd Parent/Guardian Name:

Home Phone: Cell Phone: Work Phone:


Emergency Contact Other Than Parents:

Name:

Emergency Contact Phone:

Relationship To Child:

People able to pick up/drop off child (in addition to parents):

Name(s):

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Add the values of the WHITE boxes above and enter it here:

* Don't forget to get your health history form....we need that filled out, signed, and turned in to the church!
** Here is a link to that form. Health History Form