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Child's Information:

*First Name:

*Last Name:

*Age: *Gender:

*Entering Grade:

*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 Guardians:

*Name:

*Emergency Contact Phone:

Relationship To Child:

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

Name(s):



* 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