Summer-Palooza Registration
**PLEASE COMPLETE ONE FORM PER PERSON**

For more information about Summer-Palooza, go to www.WeAreBethany.com/summer-palooza

Thank you! We can't wait to see you on July 30 from 5:30 to 7:30!


Bethany Baptist Church | 3417 Rolesville Rd | Wendell NC 27591


Name (First and Last Name) *
Your answer
Age Group (as of August 2017) *
First and Last Name of parent or guardian (put none if participant is over 18) *
Your answer
Phone Number *
Your answer
Is this a Cell Phone? *
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Emergency Contact: NAME and PHONE NUMBER *
Your answer
Does the participant have any allergies? If no, please write "no" in the blank. If yes, please explain allergy. *
Your answer
How did you hear about Summer Palooza? *
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