Child's Name *

First Name

Last Name

Child's Birth Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone (Home or Mobile)

(###)

###

####

Parent / Legal Guardian Name *

First Name

Last Name

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Allergies /Special Medical Needs *

Yes

No

Data Privacy - Use of my child's photograph on Westminster Presbyterian Church's social media sites. *

I grant permission

I do not grant permission