Please complete this 2017-18 Program Registration and Cosent Form for your child(ren).

* 1. Name of Child(ren)

* 2. School Grade (Fall of 2017)

* 3. Birthday and Age

* 4. Street Address, City, State, Zip

* 5. Parent(s)/Guardian(s) Name and Email Address

* 6. Parent(s)/Guardian(s) Home and Cell Phone

* 7. Emergency Contact Name and Contact Number

* 8. Name and Relationship of Adults Approved to Pick-Up your Child(ren)

* 9. Ministry Participation at Salem (check all programs you're interested in)

* 10. Medical or Behavioral Concerns (including allergies)

* 11. Current Medications

* 12. Parent/Guardian Consent (check all that apply)

* 13. Parent/Guardian Electronic Signature

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