Child's Name :           Boy/Girl : Select One Boy Girl

 Child's Grade this fall : Select One Going Into K-4 Going Into K-5 Going into 1st Gr Going into 2nd Gr Going into 3rd Gr Going into 4th Gr Going into 5th Gr   Allergies (if any) :

        Child's Birth date (MM/DD/YYYY):          Child's Age:

 Parent's Name :  Emergency Contact #: 
 

Address : City :        State :    
 

Zip :                  Phone :   

 E-mail   :

 Home Church : Select One Grace Fellowship None Other (specify)  Name of church if other:

   Comments/Additional Questions :
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