Registration Form for 2009-2010 Pioneer Clubs at Rock Creek Bible Church

What are the ages, names and date of birth of your children?

Name of Child   DOB
Name of Child   DOB
Name of Child   DOB
Name of Child   DOB
Name of Child   DOB

Family Information:

Parent Names
Phone
Cell Phone
Address
Email

Emergency Contact Information:

Name
Relationship
Phone
Cell Phone
Doctor's Name
Medicine Allergies

List any other specific information you wish for us to know (include other allergies, asthma, etc):

I authorize Rock Creek Bible Church to use any photos of my child(ren) taken during clubs to be placed on the church website.

I give permission to Rock Creek Bible Church to seek whatever medical attention is deemed necessary, and release the Church and its staff of any liability against personal losses of above mentioned child(ren).

Copyright © 2009 Rock Creek Bible Church. All rights reserved.
Revised: 03/30/09.