KICKIN IT OLD SCHOOL/ REGISTRATION FORM

                                                        July 31 - August 4, 2011,  6:00 to 8:30 PM

     Child's Name     

Date of Birth    Grade Completed    Age 

          Parent/Guardian      

          Address  

          Home Phone  

          Cell Phone     

           E-mail           

  Emergency contact name & number

  Person other than parent who is authorized to pick up your child

  Name of personal physician

  Phone

 Special needs/allergies

  Do you have a home church? 

  Is there a special friend your child would like to be with?

  My child may/may be photographer?