Click on event brochure below to find out about this exciting summer program!
Live free summer reading program brochure 2015.pdf
LIVE fREE Registration Information
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Student Information
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Student’s Name:
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Date of birth:
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Age:
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Grade Entering:
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Address:
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City:
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State:
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ZIP Code:
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Parent/Guardian Information
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Parent/Guardian Name:
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Relationship to Student:
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Cell:
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Phone:
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E-mail:
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Emergency Contact
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Emergency Contact Name:
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Emergency Contact Phone Number:
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Relationship to Student:
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Does this person
have your permission to pick up student for any reason? (circle) YES NO
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Spouse/other parent Information if different from emergency contact
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Relationship to Student
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Cell:
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Does this person
have your permission to pick up student for any reason? (circle) YES NO
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Please List any and all allergies or medical conditions:
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Signatures
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I verify that the information provided on this form is
valid and true. I release adult
supervisors and Prospect United Methodist Church from responsibility for
accidents during church-sponsored activities.
In case of emergency, I, the parent/legal guardian of the registered
minor, give permission to the adult supervisors to secure proper treatment
for the health and comfort of my child until I can be reached.
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Signature of applicant:
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Date:
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Media Release: permission for Capital Area North District
to use pictures: (Initials)
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Registration forms
can be returned to Prospect UMC by mail or drop off Mon, Weds. Or Fri 9 am –
1 pm
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click on Event to view more Details
