Chaos Registration
2018-2019 school year
Chaos (Wednesday’s 3-5pm)
Sunday Chaos (Sunday mornings)
Choose a main program your child will be attending. *
Required
Child’s Name *
Your answer
Child’s Date of Birth *
MM
/
DD
/
YYYY
Child’s Grade *
Your answer
Parent/Guardian’s Name *
Your answer
Parent/Guardian’s Phone Number *
Your answer
Parent/Guardian’s Email *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Allergies (ie. food, insects, medical, animal, etc.) *
Your answer
Do they carry any of the following medical devices: *
Required
Do you give permission to attend any church outings without you present, with the knowledge that there will be leaders watching your child? *
I agree and understand that if any injuries or accidents occur, Open Heart UMC is not responsible for said injury or accident. *
Required
Signature and Date *
Your answer
Submit
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