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Wednesday Night Kids Konnect Registration
Please Complete Form For Each Child
Starts August 23, 2023 6pm-7pm
Event Address: 1200 N Hwy 133 Richland, MO 65556
Contact us at (573)765-3384 or
fccrichland@gmail.com
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* Indicates required question
Child's Name
*
Your answer
Age
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Grade Entering
*
Your answer
Parent/ Caregiver Contact #1 Name, Phone
*
Your answer
Parent/ Caregiver Contact #2 Name, Phone
Your answer
Physical Address
*
Your answer
Food Allergies? Please list
Your answer
Medical Conditions
Your answer
ICE Contact First: Name, Relationship & Phone
*
Your answer
Will your child need transportation?
*
Yes
No
Required
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