Kids Klub Registration 2017-2018

• Your Name*
  Parent/Guardian Information
  First Name

  Last Name
• Address*
  Street Address *

  Address Line 2

  City *

  Province / State / Region *

  Postal Code / Zip

  Antigua and BarbudaBahamasBarbadosBelizeCanadaCosta RicaCubaDominicaDominican RepublicEl SalvadorGrenadaGuatemalaHaitiHondurasJamaicaMexicoNicaraguaPanamaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesTrinidad and TobagoUnited StatesArgentinaBoliviaBrazilChileColumbiaEcuadorGuyanaParaguayPeruSurinameUruguayVenezuelaAlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIcelandIrelandItalyLatviaLiechtensteinLithuaniaLuxembourgMacedoniaMaltaMoldovaMonacoMontenegroNetherlandsNorwayPolandPortugalRomaniaSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandUkraineUnited KingdomVatican CityAfghanistanBahrainBangladeshBhutanBrunei DarussalamMyanmarCambodiaChinaEast TimorIndiaIndonesiaIranIraqIsraelJapanJordanKazakhstanNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLebanonMalaysiaMaldivesMongoliaNepalOmanPakistanPhilippinesQatarRussiaSaudi ArabiaSingaporeSri LankaSyriaTaiwanTajikistanThailandTurkeyTurkmenistanUnited Arab EmiratesUzbekistanVietnamYemenAustraliaFijiKiribatiMarshall IslandsMicronesiaNauruNew ZealandPalauPapua New GuineaSamoaSolomon IslandsTongaTuvaluVanuatuAlgeriaAngolaBeninBotswanaBurkina FasoBurundiCameroonCape VerdeCentral African RepublicChadComorosCongoDjiboutiEgyptEquatorial GuineaEritreaEthiopiaGabonGambiaGhanaGuineaGuinea-BissauCôte d\'IvoireKenyaLesothoLiberiaLibyaMadagascarMalawiMaliMauritaniaMauritiusMoroccoMozambiqueNamibiaNigerNigeriaRwandaSao Tome and PrincipeSenegalSeychellesSierra LeoneSomaliaSouth AfricaSudanSwazilandTanzaniaTogoTunisiaUgandaZambiaZimbabwe

  Country *
• Home Phone
   
• Cell Phone
   
• Your Email
   
• Emergency Contact
  First Name

  Last Name
• Emergency Contact's Phone Number
   
• Email Communication
  May we use your email address above to relay important information like weather-related cancellations and upcoming events?
  Yes

  No
• Consent
  Do you consent to your child's (children's) name, photograph, video image and/or accomplishments being released in Bethel Evangelical Missionary Church publications such as Power Point presentations, videos, the church directory, newsletter and promotional materials?
  Yes

  No
• Name of 1st Child*
  First Name

  Last Name
• Birthdate
  MM

  /

  DD

  /

  YYYY
• Grade (September 2017)*
  >Please selectJKSK123456
• Health Card Number
• Allergies/Medications or Other Important Information
• Name of 2nd Child
  First Name

  Last Name
• Birthdate
  MM

  /

  DD

  /

  YYYY
• Grade (September 2017)
  >Please SelectJKSK123456
• Health Card Number
• Allergies/Medications or Other Important Information
• Name of 3rd Child
  First Name

  Last Name
• Birthdate
  MM

  /

  DD

  /

  YYYY
• Grade (September 2017)
  >Please SelectJKSK123456
• Health Card Number
• Allergies/Medications or Other Important Information
• Name of 4th Child
  First Name

  Last Name
• Birthdate
  MM

  /

  DD

  /

  YYYY
• Grade (September 2017)
  >Please SelectJKSK123456
• Health Card Number
• Allergies/Medications or Other Important Information