Kidz Club - Baleville Congregational Christian Church

Kidz Club – Children ages Kindergarten – 6th grade
Youth Group – 7th-10th grade

Parent's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Please list the name/phone number of an emergency contact if you can't be reached. *

How did you hear about Kidz Club/Youth Group? (copy) *

Do you attend a church? If so, which one? *

Child #1 Name *

Child #1 Grade *

Child #2 Name

Child #2 Grade

Child #3 Name

Child #3 Grade

Additional children can be listed here.

List any allergies or special needs here.