Parent Name *

First Name

Last Name

Parent Phone *

(###)

###

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Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

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Child 1 Name

First Name

Last Name

Child 1 is going into:

Pre-School

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

Child 2 Name

First Name

Last Name

Child 2 is going into:

Pre-School

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

Child 3 Name

First Name

Last Name

Child 3 is going into:

Pre-School

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

Child 4 Name

First Name

Last Name

Child 4 is going into:

Pre-School

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

Sign In/Sign Out Understanding *

I understand that I need to sign my children in when they are dropped off and that I will need to sign them out when I pick them up.

I Understand

I DO NOT Understand

Alternate Pick-Up Understanding *

I understand that I will be responsible to give notice at the registration table if someone else will be picking my children up.

I Understand

I DO NOT Understand

Picture Permission *

I give my permission for my child's picture to be taken and used by Prairie Hills Community Church.

I Agree

I DO NOT Agree