2019-2020 Dynamite Disciples Registration
Email address *
*children must be 4 years old by Sept 1st to attend.
Parent/Guardian *
Your answer
Parent/Guardian
Your answer
Address *
Your answer
City, State & Zip code *
Your answer
Email Address(s)
Your answer
Number Most Easily Reached at: *
Your answer
Phone Number 1 : *
Your answer
Phone Number 2:
Your answer
Emergency Contact #1 Name: *
Your answer
Emergency Contact #1 Number: *
Your answer
Emergency Contact #2 Name: *
Your answer
Emergency Contact #2 Number: *
Your answer
#1 Child's Name:
Your answer
#1 Child's Name Date of Birth:
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#1 Child's Name School Grade:
Your answer
#1 Child's Allergies
Your answer
#2 Child's Name:
Your answer
#2 Child's Date of Birth:
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#2 Child's Grade:
Your answer
#2 Child's Allergies
Your answer
#3 Child's Name:
Your answer
#3 Child's Date of Birth:
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YYYY
#3 Child's Grade:
Your answer
#3 Child's Allergies
Your answer
#4 Child's Name:
Your answer
#4 Child's Date of Birth:
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#4 Child's Grade:
Your answer
#4 Child's Allergies
Your answer
#5 Child's Name:
Your answer
#5 Child's Date of Birth:
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#5 Child's Name Grade:
Your answer
#5 Child's Allergies
Your answer
List the people who are allowed to pick-up your child(ren) each week: *
Your answer
List the people who are NOT allowed to pick-up your child(ren) each week: *
Your answer
Family Physician: Name / Number: *
Your answer
Preferred Hospital / Number: *
Your answer
My child(ren) may walk home after Wednesday night church school class. *
My child(ren) may ride their bike home after Wednesday night church school class. *
I/We GRANT permission for this youth’s photo/image and name to be published on the church’s Facebook page or any other social media or site operated by the First United Methodist Church. *
In the event of a medical emergency, I hereby authorize the Youth Ministry leaders, volunteers, First United Methodist Church, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical or dental care, treatment, and necessary transportation advisable for the health and safety of my child. *
I further give permission for my child to participate in all activities sponsored by the First United Methodist Church, unless I notify in writing otherwise. *
I further give permission to receive text messages to communicate cancelations, reminders, etc. about my child(ren)’s participation in all activities sponsored by the First United Methodist Church. *
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Signature: *
Your answer
Date: *
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