Quest Registration Fall 2017
For: kids ages 3 through grade 5
Date: Second Sunday in October, November, January, February, March, and April
Time: 12:30 pm - 2:30 pm
Location: Cross Roads Community Church, 271 Main Street, Leechburg, PA
Contact us at 724-845-1901 or church@crcpc.org
Name
Your answer
Birthday
MM
/
DD
/
YYYY
Completed Grade Level
Address
Your answer
Parent/Guardian Name
Your answer
Phone Number
Your answer
Emergency Phone Number
Your answer
Email Address
Your answer
Emergency Contact
Your answer
Alternate Contact Phone Number
Your answer
Medical Issues/Concerns
Your answer
Name of Person Picking up Child(ren)
Your answer
Name of Home Church
Your answer
I give my permission for my child's/children's picture to be used for publicity purposes.
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