Wednesday Club Signup 2026 – Discovery Hills Church

Number of Children To Register*

Child 1

Child's Name*

First Last

Birthdate*

MM

DD

YYYY

Grade*

School*

Teacher

Date of last tetanus shot

MM

DD

YYYY

Medications

Allergies

Additional Notes or Comments

Child 2

Child's Name*

First Last

Birthdate*

MM

DD

YYYY

Grade*

School*

Teacher

Date of last tetanus shot

MM

DD

YYYY

Medications

Allergies

Additional Notes or Comments

Child 3

Child's Name*

First Last

Birthdate*

MM

DD

YYYY

Grade*

School*

Teacher

Date of last tetanus shot

MM

DD

YYYY

Medications

Allergies

Additional Notes or Comments

Child 4

Child's Name*

First Last

Birthdate*

MM

DD

YYYY

Grade*

School*

Teacher

Date of last tetanus shot

MM

DD

YYYY

Allergies

Medications

Additional Notes or Comments

Parent / Guardian Information

Relation*

Father
Mother
Male Guardian
Female Guardian

If Guardian, relationship to child (or children)*

Name*

First Last

Email*

Address

Street Address Address Line 2 City State ZIP Code

Personal Phone or Cell Phone*

Work Phone

Add Another Guardian/Parent

YES

Parent / Guardian Information

Relation*

Father
Mother
Male Guardian
Female Guardian

Name

First Last

If Guardian, relationship to child (or children)*

Email

Address

Street Address Address Line 2 City State ZIP Code

Personal Phone or Cell Phone*

Work Phone

Child (or Children) lives with...

Relationship

Additional Instruction

Whose address should information be mailed to?

Child may be taken home by...

Names of individuals besides parent / guardian

Emergency Contacts

Name*

First Last

Phone*

Relationship*

Name*

First Last

Phone*

Relationship*

Medical Release / Permission

Agreement*

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

Relationship

Medical Information

Physician's Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Policy #

Additional Notes