Route 78 Registration Form 2018 - 2019
Cost for Route 78 is $50 per child (max of $100 per family). Please make checks payable to Peace Lutheran and note in memo line child/children names. Financial assistance is available upon request. Please fill out a separate registration form for each child. Thank you!
Child's Name *
Your answer
Grade in School in 2018 *
Birth Date *
MM
/
DD
/
YYYY
Student Cell Phone
Your answer
Student Email
Your answer
Name of Parent(s) *
Your answer
Parent Email Address *
Your answer
Parent Cell Phone *
Your answer
Home/Mailing Address *
Your answer
Please list allergies:
Your answer
Health Concerns/Special Instructions *
Your answer
I authorize my child to participate in all Route 78 related activities. *
My child's photo can be used on Peace's website and Facebook page. (Please note that photos of kids will be taken during youth activities, but if you answer "no", the pics will not be used for promotional purposes.)
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