Kidz Church Registration

Please fill out this form and click submit.

Child's Name

*

Date of Birth (DD-MM-YYYY)

*

Grade

*

Please select one option.

Pre-K Kindergarten 1 2 3 4 5 6

Name of Parent(s) or Guardian(s)

*

Address

*

Email

*

This address will receive a confirmation email

Phone

*

Emergency Contact and Relationship to Student

*

Mobile number of Emergency Contact

*

Allergies

*

Please select one option.

Yes No

If yes, please explain

Medical Concerns

*

Please select one option.

Yes No

If yes, please explain

Family Doctor and Phone Number

Name(s) of people who may pick up the child

Kidz Church leaders have permission to photograph/film the minor(s) designated above for any lawful purpose associated with this Kidz Church program.

Thank you for giving us the opportunity to teach your child(ren) more about God and give them the opportunity to have fun at the same time that they learn!

Initial

*

Date Filled Out

*

Description

Please fill out this form and click submit.

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