K!dz Life EXTREME Summer Registration

Child Information

Child's Name

Age

Gender

Male / Female

Grade entering this Fall

Allergies/Special Concerns

Child Information 2 (if applicable)

Child's Name

Age

Gender

Male / Female

Grade entering this Fall

Allergies/Special Concerns

Child Information 3 (if applicable)

Child's Name

Age

Gender

Male / Female

Grade entering this Fall

Allergies/Special Concerns

Parent Information

Parents' Names

Street Address

City

State

ZIP

Telephone

Cell phone

E-Mail

In Case of Emergency (if parents cannot be reached)

Contact Name

Relationship

Phone Number

Please list anyone (other than parents) who is authorized to pick up your child

(all persons not known by team leaders will be required to show a picture ID)
 

Authorized Person 1

Authorized Person 2

Authorized Person 3

Please enter additional comments and/or requests below

Cypress Valley Bible Church occassionally photographs or videotapes church sponsored events. Images of your child may be used for video presentations, publications, promotions, and on our website.