Child's Name *

First Name

Last Name

Child's Date of Birth

MM

DD

YYYY

Child's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian

First Name

Last Name

Phone

(###)

###

####

Parent/Guardian

First Name

Last Name

Phone

(###)

###

####

Contact (Other than above)

First Name

Last Name

Phone

(###)

###

####

Are we allowed to take your child's picture?

Yes

No

May the picture be used on Social Media (Church only)?

Yes

No