Kids on Mission Registration Form

Parent's Name

This address will receive a confirmation email

Phone

Address

Student's Name

Student's Grade

Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade

Emergency Contact Name (other than parent listed)

Emergency contact phone number

Please list any allergies this student has. Please also list any special needs of this student (ADHD, Dislexia, etc). Also please list any custody issues the staff need to know about regarding this student.

Eleventh Street Baptist Church may, from time to time, document the activities of the ministry with photos or videos. I hereby assign and grant to Eleventh Street Baptist Church and assign the unqualified right to the ownership, use and proceeds of all photographs or video of me or my minor child, without reservation or limitation, including use of photographs or video of me or my minor child for, but not limited to, advertising, educational and promotional purposes.

Yes No

The child listed above is allowed to attend Kid's on Mission at 11th Street Baptist Church, every Wednesday evening from 6:30 - 7:30 pm. TYPING YOUR NAME BELOW IS EQUIVELENT TO YOUR SIGNATURE

Description

Wednesdays 6:30 pm

Please fill out this form and click submit.

Kids on Mission Registration Form

Description

Please Fix the Following