Released Time Registration
Tuesday's  from 1:20 PM - 2:20 PM
March 7 - April 11, 2022

For children in 1st - 5th Grade
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Information
When: Tuesday afternoons from 1:20PM-2:20PM
Dates: 3/7, 3/14, 3/21, 3/28, 4/4, 4/11
Students will be bussed from the elementary school to Asbury Methodist Church - 19801 Route 322 Strattanville, PA 16258

Good News Club will only take place on full days of school (2-hour delays included- but not on early dismissals or days off).

Hosted and Conducted by: Child Evangelism Fellowship of Venango, Forest, & Clarion Counties, PA ONLY.                  
This information will be disregarded for other areas.
Contact: Starla Purinton  814-227-7530
Child's Birth Date
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Child's Age
Student Grade *
Gender
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Home Address
List any security/custody issues with child:
List any special needs of child (ADD, Asperger's, Dyslexia, etc.):
List any allergies of child:
Photo/Video Release Agreement*
Child Evangelism Fellowship may, from time to time, document the activities of the ministry with photos or videos of club activities.  I hereby assign and grant to Child Evangelism Fellowship Inc., its subsidiaries and successors, and assign the unqualified right to the 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 of me or my minor child for advertising and promotional purposes.
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Parent/Guardian Name *
Parent/Guardian Phone # *
Parent/Guardian Email *
Is either parent in the military?
Emergency Contact Name *
Emergency Contact Phone # *
Second Emergency Contact Person
Second Emergency Contact Phone #
Church Name if attending
Parent/Guardian Permission*
My child(ren) is allowed to attend the Good News Club on the scheduled days listed above. - Your  typed E-signature is your legal and binding permission.

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