Kids Klub Registration

Kids Klub Registration 2019-2020

Please complete this form and press "submit".
THURSDAY EVENINGS 6 - 7:30 p.m.
(Begins September 19)
Children JK - Grade 6
$35/child to a maximum of $75/family
(Payment can be made on the first evening).

Your Name*
Parent/Guardian Information
First Name
Last Name
Address
Street Address
Address Line 2
City
Province / State / Region
Postal Code / Zip
Country
Main Contact Phone Number*
Cell Phone Number (if different from main contact number)
Your Email
Emergency Contact (for use only if we can't reach you)
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 2019)*
Health Card Number
Allergies/Medications or Other Important Information
Name of 2nd Child
First Name
Last Name
Birthdate
MM
/
DD
/
YYYY
Grade (September 2019)
Health Card Number
Allergies/Medications or Other Important Information
Name of 3rd Child
First Name
Last Name
Birthdate
MM
/
DD
/
YYYY
Grade (September 2019)
Health Card Number
Allergies/Medications or Other Important Information
Name of 4th Child
First Name
Last Name
Birthdate
MM
/
DD
/
YYYY
Grade (September 2019)
Health Card Number
Allergies/Medications or Other Important Information