KidZone Registration

Wednesdays 6:30-7:30pm | Thanks for your interest in Southtown's Wednesday Night Kid's Ministry! Please fill this out so we are best able to serve you and your child!

Basic Information

Child's Name

*

Parent/Guardian Name

*

Address

*

Cell Phone

*

Parent Email

*

This address will receive a confirmation email

Age Information

Current Age (must be 4 or older)

*

Child's Birthday MM/DD/YY

*

Grade in School

*

Please select one option.

PK K 1st 2nd 3rd 4th 5th 6th

Anything Else We Should Know?

Please list any medical or other information we need to know (please include any allergies or known behavioral issues)

Emergency Contact (other than parent/guardian listed above)

Emergency Contact Name

*

Emergency Contact Phone Number

*

Dismissal Information

Who may pick your child up? Separate names with a comma

*

Other Information

Does your child attend Sunday School?

*

Please select all that apply.

Yes No

If so, where?

Is your child an invited guest of a specific person?

*

Please select all that apply.

Yes No

If so, who?

May we have permission to photograph your child?

*

Please select all that apply.

Yes No

If we can photograph your child, may we have permission to use your child's photograph for the purpose of promotion or on our church social media?

*

Please select all that apply.

Yes No

Description

Wednesdays 6:30-7:30pm

Thanks for your interest in Southtown's Wednesday Night Kid's Ministry! Please fill this out so we are best able to serve you and your child!

Please Fix the Following

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