Children's Registration - West Center Baptist Church

Building Healthy Disciples for World IMPACT

First Service 8:30 AM | Sunday School 9:45 AM | Second Service 11:00 AM

Parent /Guardian Information
Last Name: *
First Name(s): *
Address: *
City/State: *
Main Phone #: *
2nd Contact #:
Email:
Home Church:
Child 1:
Last Name: *
First Name: *
Date of Birth (mm/dd/yy): *
Age:
Grade (Fall 2011): *
Gender: *	Male Female
Does this child have any medical conditions (allergies, medications, etc.) that we should be aware of?
:	Yes No
If yes:
Child 2:
Last Name:
First Name:
Date of Birth (mm/dd/yy):
Age:
Grade (Fall 2011):
Gender:	Male Female
Does this child have any medical conditions (allergies, medications, etc.) that we should be aware of?
:	Yes No
If yes:
Child 3:
Last Name:
First Name:
Date of Birth (mm/dd/yy):
Age:
Grade (Fall 2011):
Gender:	Male Female
Does this child have any medical conditions (allergies, medications, etc.) that we should be aware of?
:	Yes No
If yes:
Emergency Contact Information Needed for 6:00 - 8:30pm:
Will a parent/guardian be working at this event?
: *	Yes No Maybe
Name: *
Phone #: *
Name:
Phone #:
Thank you for completing this form. We pray that your children will learn to know God and His son, Jesus throught this fun filled week!! Invite your friends! God Bless!