Emmaus Childrens' Ministries Registration
Last Name of Child(ren)
Your answer
Parent Names
Your answer
Mailing Address
Your answer
Emergency Contact Name (if parents not available)
Your answer
Emergency Contact Phone Number
Your answer
Please list children (ages infant through 5th grade) in your household.
Child Name
Your answer
Birth Date: (mm/dd/year)
Your answer
Grade in '16-'17
This child will participate in the following (check all that apply):
Child Name
Your answer
Birth Date: (mm/dd/year)
Your answer
Grade in '16-'17
This child will participate in the following (check all that apply):
Child Name
Your answer
Birth Date: (mm/dd/year)
Your answer
Grade in '16-'17
This child will participate in the following (check all that apply):
Child Name
Your answer
Birth Date: (mm/dd/year)
Your answer
Grade in '16-'17
This child will participate in the following (check all that apply):
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