Child's Last Name:

Child's First Name:

Date of Birth (00/00/00):

Age of Child as of September 1:

Grade Entering in September:

Does this child have any special needs or allergies? (if YES please explain)

Parent/Guardian Last Name:

Parent/Guardian First Name:

Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Email Address:

Emergency Contact Name:

Emergency Contact Phone Number:

What church do you normally attend?

It is understood that every precaution will be taken for the safety and well-being of my child, but in the event of accident or sickness, Kenmore Alliance Church, its staff and its volunteers are hereby released from any liability.

Do you agree to the above statement?

Would you like more information about our church or our children's ministry?

Would you like ot be contacted by one of our staff members?

Would you like to volunteer to help in our church or our children's ministry?