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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
Antigua and Barbuda
Bahamas
Barbados
Belize
Canada
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Columbia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Côte d\'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
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)
*
>
Please select
JK
SK
1
2
3
4
5
6
Health Card Number
Allergies/Medications or Other Important Information
Name of 2nd Child
First Name
Last Name
Birthdate
MM
/
DD
/
YYYY
Grade (September 2019)
>
Please Select
JK
SK
1
2
3
4
5
6
Health Card Number
Allergies/Medications or Other Important Information
Name of 3rd Child
First Name
Last Name
Birthdate
MM
/
DD
/
YYYY
Grade (September 2019)
>
Please Select
JK
SK
1
2
3
4
5
6
Health Card Number
Allergies/Medications or Other Important Information
Name of 4th Child
First Name
Last Name
Birthdate
MM
/
DD
/
YYYY
Grade (September 2019)
>
Please Select
JK
SK
1
2
3
4
5
6
Health Card Number
Allergies/Medications or Other Important Information
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