Love, Joy, Peace...
Ebenezer Baptist Church
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CHILD INFORMATION
Child's First Name (
Required
)
Child's Last Name (
Required
)
Child's Age (
Required
)
Age - potty trained to 12 years old
Child's Birthday (
Required
)
Is your child potty trained? (
Required
)
All young children are required to be potty trained
Yes
No
Allergy/Medical/Special Needs
PARENT/CONTACT INFORMATION
Parent/Guardian Name (
Required
)
Home Address (
Required
)
|
EMERGENCY CONTACTS
Emergency Contact #1 - Name (
Required
)
Emergency Contact #1 - Phone (
Required
)
Emergency Contact #2 - Name
Emergency Contact #2 - Phone
AUTHORIZED PICKUP PERSON(S)
Authorized Pickup Person #1 (NAME & PHONE) (
Required
)
You must enter at least (1) authorized pickup person. ID will be required for pickup
Authorized Pickup Person #2 (NAME & PHONE)
ID will be required for pickup
Do you attend church on Sundays?
Yes
No
If so, where?
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