Click HERE to Register! | Ebenezer Baptist Church

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

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?

If so, where?

Ebenezer Baptist Church