Wednesday Registration

Child's Name (One per form, please) 

 

Child's Date of Birth        School Grade (2012-2013)  K5 1st 2nd 3rd 4th 5th

 

Parent or Caregiver's Name(s) 

 

Home #      Cell# 

 

Work # 

 

Mailing Address 

 

Parent's email address 

 

Emergency Contact Name 

 

Relationship to Child    Telephone # 

 

Allergies or other medical conditions we should know about:

 

Other Comments:

 

I would like my child picked up from school and taken to church:  yes no

 

He/she attends: