Good News Club Registration Form Winter 2024

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Email *

Child's First and Last Name *

School *

Grade and Homeroom Teacher *

Gender *

Male

Female

Birthdate *

YYYY

Age *

Street Address *

City *

State *

Zip Code *

Any security/custody issues with this child

Any special needs (ADD, Asperger's, Dyslexia, Etc)

Allergies *

Home Phone

Parent/Guardian#1 Work/Cell Phone

Parent/Guardian #2 Work/Cell Phone

Do you have a home church? If so, where?

Is either parent in the military?

Emergency Contact 1 Name and Phone Number *

Emergency Contact 2 Name and Phone Number *

Permission for Pick Up- In addition to those listed above, the following people are allowed to pick up my child: (include name and phone number) *

Electronic Signature

The typed name below stands as a signature stating the above information is correct. The signature below also confirms the child on this form is allowed to attend the Good News Club at the Independence Elementary School, every Wednesday after school. There will be no clubs on half days or school holidays. Good News Club will run from 2/7/2024 to 3/27/2024. I understand it is my responsibility to pick up my child at 5:00pm and failure to do so will jeopardize my child's continued participation. Please include the date of signature.

OPTIONAL Photography and Video Releases

Child Evangelism Fellowship may, from time to time, document the activities of the ministry with photos or videos.

I hereby assign and grant to Child Evangelism Fellowship Inc, its subsidiaries and successors, and assign the unqualified right to ownership, use and proceeds of all photographs or video of me or my minor child, without reservation or limitation, including use of photographs or video or me or my minor child for, but not limited to, advertising, educational, and promotional purposes.

Please type your signature below.

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