Amped Registration Form
Use this form to register your child for Amped at Bethany Baptist Church. For ages 3yrs to 5th grade. Wednesday nights in June and July
Child's name *
Your answer
Parent/Guardian Name *
Your answer
Address *
Street address, city, state, and zip code.
Your answer
Mailing Address (If different from above)
Your answer
Contact info
Cell Phone *
Your answer
Email *
Your answer
Home Phone
Your answer
Work Phone
Your answer
Age info
Birth Date *
MM
/
DD
/
YYYY
Last grade completed in School *
Your answer
Medical Info
Please list any medical or other information we need to know. (Please include allergies) *
Your answer
Emergency Contacts (If different from parent/guardian above)
Name
Your answer
Phone
Your answer
Name
Your answer
Phone
Your answer
Dismissal info
Who may pick up your child at the end of each night at Amped? *
Your answer
Other Info
May we have permission to photograph your child? *
Required
May we have permission to use your child's photograph for the purpose of promotion? *
Required
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