Pioneer Clubs 2018/19 Registration Form
$80/year
Child's First Name *
Your answer
Child's Last Name *
Your answer
Gender *
Birthdate (MM/DD//YYYY) *
MM
/
DD
/
YYYY
Address *
Your answer
City *
Your answer
Postal Code *
Your answer
Name of Parent/Guardian 1 *
Your answer
Name of Parent/Guardian 2 *
Your answer
Phone Number (Home) *
Your answer
Phone Number (Cell) *
Your answer
Email *
Your answer
Allergy and/or other medical conditions
Your answer
Home Church
Your answer
Fellowship Group
Your answer
Name of Emergency Contact (relationship) *
Your answer
Phone Number of Emergency Contact *
Your answer
Additional Comments
Your answer
Permission for outdoor activities *
I give permission for the above-named participant to take part in short trips to nearby parks, short walks, or outdoor activities within Pioneer Clubs' time (Friday 7:30 pm - 9:15 pm)
Media Release *
I, the parent/guardian of the above-named participant, agree to permit reasonable use of photos and videos of participant in promoting the program (i.e. Pioneer Clubs newsletter and Children's Ministry bulletin board).
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