Registration Form

God's Big Backyard: Where Kids have a blast serving Jesus!

(one per child please)

Name:                                                                                                                            

Street address:                                                                                                                

City:                                                     State:                       ZIP:                                   

Home telephone: _________________________Home e-mail address:                             

Date of birth:                                                       Age:                                                      

Last school grade completed:                             School child is attending:                          

In case of emergency, contact:                                                                                         

Name of Mother:                                                 Phone:                                                 

Name of Father:                                                 Phone:                                                 

Other:                                                                                                                          

Allergies or other medical conditions:                                                                                

Does your child have special needs that we need to be aware of? (Continue on back if necessary.)   __________________________________________________________________________________

Name of a special friend your child might like to be with:                                                     

Will your child be bringing any friends?                                                                              

Name(s) & age(s):                                                                                                               

Home church:                                                                                                                

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