5 Eleven Kids Pre-Registration Form

IMPORTANT, PLEASE READ ME:
Where it says "Your Name" at the top, please fill this out with YOUR NAME (the parent/legal guardian filling out this form)

Your name *

Email address *

STOP!

ADD CHILDREN HERE.
Please add your children by clicking "Add Child" and add any additional parents/legal guardians by clicking "Add Adult."

Household members

Phone number *

Address

Birthdate

Gender

Medical note

Are there any custody issues we need to be aware of?

Information for your visit.

Date of your planned visit. *

Release *

I grant permission for any 5 Eleven Children's volunteer or church official in charge of First Aid to obtain necessary medical attention in case of sickness or injury. As a participant, my child may be photographers or videotaped during normal activities and these photos/videos may be used in promotional materials.

Signature *

PRINT NAME BELOW TO SIGN RELEASE.