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GAK Registration 2015-2016
Trinity Church
250 Sweinhart Road
Boyertown
Wednesday nights from 6:30-8:00 p.m.
October 7, 2015-April 27, 2016
Age 3 through Grade 5
gak@trinityboyertown.org
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* Indicates required question
Parent/Guardian Last Name
*
Your answer
Parent/Guardian First Name(s)
Your answer
Address
*
Your answer
Phone Number
*
Your answer
Alt Phone number
Your answer
Additional Phone (optional)
Your answer
email address
*
(used for communications during GAK, to notify you of cancellations, special event nights, etc).
Your answer
Emergency Contacts (in the event parent(s) listed above cannot be reached)
Please include NAMES and PHONE NUMBERS
Your answer
Can your child be released to the Emergency Contact people listed above?
*
Choose
Yes
No, PARENTS ONLY
First Name Child #1
*
Your answer
Last Name Child #1
*
Your answer
Date of Birth
*
Must be at least 3 years old by September 1, 2015
MM
/
DD
/
YYYY
Grade
*
Choose
Preschool (must be 3yrs old by Sept 1, 2015 and potty trained by 9/10/13)
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Allergies or Medical Concerns
*
If none, please write NONE
Your answer
Any other information that would be helpful for us to know?
Your answer
First Name Child #2
Your answer
Last Name Child #2
Your answer
Date of Birth
Must be at least 3 years old by September 1, 2015
MM
/
DD
/
YYYY
Grade
Choose
Preschool (must be 3 years old by Sept 1, 2015 and potty trained by 9/10/13)
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Allergies or Medical Concerns?
If none, please write NONE
Your answer
Any other information that would be helpful for us to know?
Your answer
First Name Child #3
Your answer
Last Name Child #3
Your answer
Date of Birth
Must be at least 3 years old by September 1, 2015
MM
/
DD
/
YYYY
Grade
Choose
Preschool (must be 3 yrs old by Sept 1, 2015 and potty trained by 9/10/13)
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Allergies or Medical Concerns?
If none, please write NONE
Your answer
Any other information that would be helpful for us to know?
Your answer
First Name Child #4
Your answer
Last Name Child #4
Your answer
Date of Birth
Must be at least 3 years old by September 1, 2015
MM
/
DD
/
YYYY
Grade
Choose
Preschool (must be 3 yrs old by Sept 1, 2015 and potty trained by 9/10/13)
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Allergies or Medical Concerns?
Your answer
Any other informatoin that would be helpful for us to know?
Your answer
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