Wednesday Night Program registration

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Please fill out 1 form for each child.

Starts September 14 from 5:30-7 pm.

A meal is provided so please fill out if there is any food allergies.

Please sign liability, photo, and medical releases the first time your child attends.

For more information please see fpcleclaire.org, email fpcleclaire@gmail.com, or call/text Wendi at 563-9497871

Name *

Birthday *

YYYY

Grade *

School attending

Allergies or medical concerns

Parent/guardian name *

Email *

Address *

Phone number *

Youth's phone number

Emergency Contact (Name and phone) *

Who else can pick up your child *

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