registration

Light Zone Registration 2010-2011

St. John's Sunday School "Light Zone" Registration Form

One Form Per Child

Child's First Name: *
Child's Last Name: *
Current Grade: *
Age: *
Date of Birth: *
Home Phone: *
Date of Baptism:
Mother's Name: *
Address: *
City: *
Zip: *	(5 digits)
Home Phone: *
Cell Phone:
Email Address:
Church Affiliation:
Church Membership:
Father's Name: *
Address: *
City: *
Zip: *	(5 digits)
Home Phone: *
Cell Phone:
Email:
Church Membership:
Church Affiliation:
Emergency Contact: *
Emergency Contact Phone: *
Relationship to Student:
Food Allergies or Other Medical Concerns:
Family Physician:
Physican Phone:
You can call me to help as a:	Teacher
	Other
I understand my child's picture may be taken and could be used for display or advertisement	Yes