REGISTRATION INFORMATION

Please Note: You may only enter Your Child or Children.
If a friend wishes to attend, their parent / legal guardian must register them.

PARENTS TAKE NOTE: “We will be walking to Westlake Park for some
fishing.  This is 3 blocks from the church, and we will not be on any busy streets.”
**This will be available for children in 2nd Grade - 6th Grade only. **

#1 Child Attending First/Last Name: Grade Just Completed (K - 6th) :
#2 Child Attending First/Last Name: Grade Just Completed (K - 6th) :
#3 Child Attending First/Last Name: Grade Just Completed (K - 6th) :
#4 Child Attending First/Last Name: Grade Just Completed (K - 6th) :


Parent / Legal Guardian First/Last Name:

Child Address:

City:      Apt. Number :      Zip:

Emergency Phone #1 (Please include area code):

Emergency Phone #2 (Please include area code):

Parent/Legal Guardian E-Mail Address: This is only if we need to notify you via e-mail.

ALLERGIES/SPECIAL NEEDS - Please Enter / List or type "None"

Allergies / Special Needs / None:

No Fee - Parent / Legal Guardian Consent Required.
Please be sure to type in your full name as Parent / Legal Guardian below.
This typed consent giving your permission that the above listed child(ren) from the same family may participate at
Friendship National Park Day Camp at Bloomingdale Church is as valid as a "signed consent form".