Child's Name *

First Name

Last Name

Gender *

Male

Female

Date of Birth *

MM

DD

YYYY

Parent's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address (if different)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do you give consent for participating churches to use pictures of child on the church website/Facebook for informational or promotional purposes? *

Grant consent

DO NOT grant consent

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

I Have More than 1 Child Registering

Same emergency contact information

Yes

No