Learner's First Name: 
Learner's Last Name: 
Gender
Birthday (i.e. MM/DD/YYYY)
LAST Grade Completed:
(No children under 5 years of age. No child care available.)
Mother's First Name:
Mother's Last Name:
Father's First Name:
Father's Last Name
(If Different):
Address:
City:
State:
Zip: 
Cell/Home Phone:
(Phone where you can receive text messages, i.e. info, emergency, etc.)
E-Mail Address:
Allergies (List all)
(Leave Blank if None)
Medical & Special Needs (List all)
(Leave Blank if None)
Emergency Contact Name (1):
Emergency Contact Phone (1): (xxx-xxx-xxxx)
Emergency Contact Name (2):
Emergency Contact Phone (2): (xxx-xxx-xxxx)
Authorized Pickup (1):
Authorized Pickup (2):
Name of Church You Normally Attend:
May we have permission to photograph your child? (i.e. to be used in VBS crafts):
Comments