WNL! 2018/2019 Fall Registration for Children and Youth
Fall 2018/2019 WNL Registration for Children and Youth

Fall Semester: Classes will begin September 12, 2018 through December 12, 2018; except the following Wednesdays:
October 10 (Fall Break), October 31 (Halloween), and November 21 (Thanksgiving week)

What is the cost per semester? 2, 3, 4 year old: $40 per child
K-High School: $50 per child with a family maximum of $125

Free Nursery for children under 2 years old

Payment is due with registration or on the first night of WNL (September 12)

Please complete a separate registration form for each individual you wish to register

Child's Full Name *
Your answer
Date of Birth (mm/dd/yyyy) *
Your answer
Grade (as of Fall 2018/2019) *
Does your child have any allergies? Carry an EPI pen? *
Your answer
Does your child have any health conditions or special needs/restrictions?
Your answer
Please list people who may pick up your child *
Your answer
School Attending *
Your answer
Parents First and Last Names *
Your answer
Street Address *
Your answer
City/Zip *
Your answer
Parent 1 Cell Phone (xxx-xxx-xxxx) *
Your answer
Parent 1 Email *
Your answer
Parent 2 Cell Phone (xxx-xxx-xxxx)
Your answer
Parent 2 Email
Your answer
Home Telephone (xxx-xxx-xxxx)
Your answer
Emergency contact other than parent *
Your answer
Emergency contact's number (xxx-xxx-xxxx) *
Your answer
Physician's name *
Your answer
Physician's number (xxx-xxx-xxxx) *
Your answer
Church Affiliation *
Authorization for treatment of a minor: My child/children listed above have my permission to participate in all the activities of the WNL ministry at First Presbyterian Church. I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the person listed on this form. In the event I cannot be reached or the alternate contact person cannot be reached in an emergency I hereby give my permission to the physician or dentist selected by the activity leader (acting as agent/representative for First Presbyterian Church) to hospitalize, to secure medical treatment and/or emergency medical transport for my child as deemed necessary. *
Photo Release: I give permission for my child’s photograph to be taken during WNL events and used for internal publicity purposes and FPC church publications (including our weekly email newsletter and the church website). *
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