EmailMe Form - ARK REGISTRATION

(1) Child's Full Name *

Date of Birth *

Current Age *

Grade in School *

(2) Child's Full Name

Date of Birth

Current Age

Grade in School

(3) Child's Full Name

Date of Birth

Current Age

Grade in School

(4) Child's Full Name

Date of Birth

Current Age

Grade in School

Parent/Guardian Name *

Address *

Street Address City State / Province / Region Postal / Zip Code

Phone *

### - ### - ####

Email

Emergency Contact *

Emergency Phone *

### - ### - ####

Church Affiliation

Permission-walk to Saint John after school? *

Yes

No

Permission-walk home from Saint John after ARK? *

Yes

No

Permission-to use photographs or videos of my child(ren) on TV or web page? (names will not be posted) *

Yes

No

Please list any food allergies/health issues. (We will be serving a light snack during ARK)

For Parents/Guardian, please indicate if you would be willing to help at ARK

Yes

No

I have a Middle or High School student who would be willing to help.

Yes

No

Student's Full Name