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W
orship
O
n
W
ednesday 2024-25 Registration Form
Event Timing: Wednesday's during the school year from 5:30-7:00pm
Event Address: 1100 N. Calhoun Street, West Liberty, IA 52776
Contact us at (319) 627-2989 or
firstchurchunited@gmail.com
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* Indicates required question
Name of child
*
Your answer
Primary Parent contact name
*
Your answer
Primary Parent contact email address
*
Your answer
Primary Parent contact telephone number
*
Your answer
Primary Parent/Child Home Address
*
Your answer
Additional adult(s) authorized to pick up your child
Your answer
Secondary parent or contact person email address
Your answer
Secondary parent or contact person phone number
Your answer
Child's date of birth
MM
/
DD
/
YYYY
Any Allergies?
*
None
Other:
Child's grade in school fall of 2024
*
Choose
Toddler
Preschool
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
Any special needs or concerns you would like to share regarding your child?
Your answer
I give my permission for my child to have his/her picture taken for items such as our church website, brochures, Facebook, the West Liberty Index.
*
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No
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