Registrant Name (required):

Registrant Phone (required):

Registrant Email (required):

Child 1
Name (First, Middle Initial, Last):
Male   Female     Date of Birth (MM/DD/YYYY):   Age:
Current School Grade: Select One Below Nursery/Preschool Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade

Child 2
Name (First, Middle Initial, Last):
Male   Female     Date of Birth (MM/DD/YYYY):   Age:
Current School Grade: Select One Below Nursery/Preschool Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade

Child 3
Name (First, Middle Initial, Last):
Male   Female     Date of Birth (MM/DD/YYYY):   Age:
Current School Grade: Select One Below Nursery/Preschool Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade

Child 4
Name (First, Middle Initial, Last):
Male   Female     Date of Birth (MM/DD/YYYY):   Age:
Current School Grade: Select One Below Nursery/Preschool Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade

Child 5
Name (First, Middle Initial, Last):
Male   Female     Date of Birth (MM/DD/YYYY):   Age:
Current School Grade: Select One Below Nursery/Preschool Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade

Parent/ Guardian Information
Father’s /Guardian Name:

Mother’s/Guardian Name:

Street Address:

Secondary Address (if different from above):

City   State   Zip

Home Phone   Work Phone

Father’s Cell Father’s E-mail

Mother’s Cell Mother’s E-mail

Emergency Contact Person(s) Other Than Yourself:

Name

Home   Work   Cell Other

Name

Home   Work   Cell Other

Please list the names of all adults, other than yourself, who you have authorized to check your child in and out.

Does your child have any medical, physical, or special needs (including emotional, behavioral, disabilities, ADHD, allergies, etc)? Yes   No

If Yes, please specify the child and need:

Please select the nursery and preschool ministries that you wish to enroll your child/children:

Jungle Jubilee (Sunday Worship)    Safari (Sunday Evening Bible Fellowship)   AWANA

Please select the kindergarten/elementary ministries that you wish to enroll your child/children.

The Zone (Sunday Kidz Worship)    Kid Encounter (Sunday Evening Bible Fellowship)   AWANA

I plan to attend a Wednesday / Sunday evening Bible Fellowship. Yes   No

Would you consider serving in a Wednesday or Sunday preschool, elementary, or student ministry?

Yes   No

Do you actively and regularly attend a local church in the area? Yes   No

If Yes, where do you attend:

Parental/ Legal Guardian & Child’s Statement of Consent and Cooperation

I certify that I am the legal parent/guardian of the above listed child/children and grant permission for my child/children to attend the Preschool & Elementary Children’s ministries of Emmanuel Baptist Church. I further give permission for the use of my child/children’s image in church promotional materials (church power-points, brochures, & web-site).

I certify (Checking this box will function as your signature)