Kids’ Club Registration

Fill out the form below to register for Kids’ Club. * Denotes Required Field
Click here to Print Kids’ Clubs Order Form.

Parents' Information

Mother's Name*
Father's Name*
Address*
City*
State*
Zip*
Home Phone*
Cell Phone*
Email*

Emergency Contact Information

Emergency contact and people permitted to pick up child (please enter name as it appears on driver's license as they will be asked for ID).
Name*
Phone Number*
Relationship to Child*
Name*
Phone Number*
Relationship to Child*

Child One

Child's Name*
Nickname
Birth Date
Kids' Club*
Food Allergies
Other Allergies
Medical Conditions
Special Accomodations

Child Two (if applicable)

Child's Name
Nickname
Birth Date
Kids' Club
Food Allergies
Other Allergies
Medical Conditions
Special Accomodations

Child Three (if applicable)

Child's Name
Nickname
Birth Date
Kids' Club
Food Allergies
Other Allergies
Medical Conditions
Special Accomodations

Child Four (if applicable)

Child's Name
Nickname
Birth Date
Kids' Club
Food Allergies
Other Allergies
Medical Conditions
Special Accomodations

Verification

I verify that the above information is correct.

Disclaimer

Photographs are sometimes taken of children's ministry activites for publicity and promotional purposes, which include but are not limited to, in-house presentations, church web sites, brochures and newsletters. Children's names or information are never used without specific permission. By checking this box, you are releasing Perry Hall Baptist Church to use photographs of your child as stated above.
I Agree

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