Wednesday Night Program Registration form

Please fill out this form to register your child(ren) for our Wednesday Night Program.
The first day your bring your kids there will be permission slips to sign.

Parent/Guardian Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Text Messages Reminders

If you select yes below, you agree to receive text message reminders about our Wednesday Night Program

Yes

Pick-Up

Please list all those who have permission to pick-up your child

Emergency Contact - Name

in case we are unable to get a hold of you

First Name

Last Name

Emergency Contact - Phone

(###)

###

####

Emergency Contact - Relationship to child(ren)

Please list all your children participating in our program

Child 1 - Name

First Name

Last Name

Child 1 - Grade

Child 1 - Date of Birth

Child 1 - Health Info

Child 2 - Name

First Name

Last Name

Child 2 - Grade

Child 2 - Date of Birth

Child 2 - Health Info

Child 3 - Name

First Name

Last Name

Child 3 - Grade

Child 3 - Date of Birth

Child 3 - Health Info

Child 4 - Name

First Name

Last Name

Child 4 - Grade

Child 4 - Date of Birth

Child 4 - Health Info

Child 5 - Name

First Name

Last Name

Child 5 - Grade

Child 5 - Date of Birth

Child 5 - Health Info

Additional Comments