Number of Children To Register*1234Child 1Child's Name* First Last Birthdate* MM DD YYYY Grade*Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeSchool*TeacherDate of last tetanus shot MM DD YYYY MedicationsAllergiesAdditional Notes or CommentsChild 2Child's Name* First Last Birthdate* MM DD YYYY Grade*Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeSchool*TeacherDate of last tetanus shot MM DD YYYY MedicationsAllergiesAdditional Notes or CommentsChild 3Child's Name* First Last Birthdate* MM DD YYYY Grade*Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeSchool*TeacherDate of last tetanus shot MM DD YYYY MedicationsAllergiesAdditional Notes or CommentsChild 4Child's Name* First Last Birthdate* MM DD YYYY Grade*Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeSchool*TeacherDate of last tetanus shot MM DD YYYY AllergiesMedicationsAdditional Notes or CommentsParent / Guardian InformationRelation*FatherMotherMale GuardianFemale GuardianIf Guardian, relationship to child (or children)*Name* First Last Email* Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Personal Phone or Cell Phone*Work PhoneAdd Another Guardian/Parent YES Parent / Guardian InformationRelation*FatherMotherMale GuardianFemale GuardianName First Last If Guardian, relationship to child (or children)*Email Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Personal Phone or Cell Phone*Work PhoneChild (or Children) lives with...RelationshipAdditional InstructionWhose address should information be mailed to?Child may be taken home by...Names of individuals besides parent / guardianEmergency ContactsName* First Last Phone*Relationship*Name* First Last Phone*Relationship*Medical Release / PermissionAgreement*I give permission for each child listed above to participate in the Discovery Hills Church Wednesday Club after-school tutoring program. I agree *In the event I cannot be reached in an emergency, I give the adult sponsor of Wednesday Club permission to consent to any x-ray, examination, anesthetic, or medical or surgical services needed on the advice of a physician or surgeon licensed to practice in the state of treatment when the need for such treatment is immediate. I agree Please type your full name as a consent*Today's Date* MM DD YYYY RelationshipMedical InformationPhysician's Name First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy #Additional Notes