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2024-2025 Pioneer Club Registration
La Plata First Baptist Church
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Email
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Your email
Club member name:
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Your answer
Address: Street, City, State & Zip code
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Your answer
Home phone:
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Your answer
Age:
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Your answer
Birth Date
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Your answer
Grade:
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Your answer
Brothers and sisters also in Pioneer Clubs (list names and ages)
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Your answer
Parent or guardian name:
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Your answer
Phone number - Home & Work
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Your answer
My child has the following allergies, medical concerns, or special learning needs.
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Emergency contact if parent cannot be reached - Name & phone number.
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