KidsXP Participant Registration (Wednesday Nights)

August 2nd - September 20th @ 6:00pm - 7:30pm | Kindergarten thru 5th grade students ONLY!

Please fill out this form and click submit.

Child's Information

Child's Name

*

Child's Gender

*

Please select all that apply.

Male Female

Child's Birthdate

*

Grade

*

Please select one option.

Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade

Child's Allergies, Medical, Special Needs, & Instructions

Parent / Guardian Information

Parent / Guardian Name

*

Address

*

Cell Phone

*

Home Phone

Email

*

This address will receive a confirmation email

Emergency Contact

Contact #1 Name

*

Contact #1 Phone

*

Contact #2 Name

Contact #2 Phone

Authorized Pickup

Authorized Pickup #1

*

Authorized Pickup #2

Authorized Pickup #3

Authorized Pickup #4

Photograph

May we have permission to photograph your child?

*

Please select all that apply.

Yes No

May we have permission to use your child's photograph in our church publications, on our website, and on social media?

*

Please select all that apply.

Yes No

Additional Information

How did you hear about us?

Other Comments:

Description

August 2nd - September 20th @ 6:00pm - 7:30pm

Kindergarten thru 5th grade students ONLY!

Please fill out this form and click submit.

Please Fix the Following

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