BLAST!

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* 1. Child's Name

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* 2. Parent/Guardian Name:

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* 3. Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 4. Date of Birth

MM / DD / YYYY Format

Date

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* 5. Age

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* 6. Grade

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* 7. Home Church

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* 8. Allergies/Medical Information

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* 9. Emergency Contacts

Emergency Contact 1

Phone Number

Emergency Contact 2

Phone Number

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* 10. Dismissal Information (Name and contact of person(s) who may pick up this child from BLAST!

Name of Contact

Phone Number

Name of Contact

Phone Number

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* 11. I here by grant permission to Millerton Wesleyan Church to use my child's photograph(s) on its website, Facebook, or in other church related material online or in printed publications for the church without further consideration.

Electronic Signature

Date