Winter 2017/2018 WNL Registration for Children/Youth

Winter Semester:  Classes will begin January 10th, 2018 through March 21st, 2018.

What is the cost per semester?  2, 3, 4 year old:  $40 per child
K-High School:  $50 per child with a family maximum of $125.

Free Nursery for children under 2 years old.

Payment is due with registration or on the first night of WNL (January 10).

Please complete a separate registration form for each individual you wish to register.

*Child's Full Name

*Date of Birth (mm/dd/yyyy)

*Grade (as of Fall 2017/2018)

*School Attending

*Parents First and Last Names

*Street Address


*Home Telephone (xxx-xxx-xxxx)

*Father's cell phone number (xxx-xxx-xxxx)

*Father's email address

*Mother's cell phone number (xxx-xxx-xxxx)

*Mother's email address

*Church Affiliation

*Please list people who may pick up your child

*Emergency contact other than parent

*Emergency contact's home number (xxx-xxx-xxxx)

*Emergency contact's cell number (xxx-xxx-xxxx)

*Does your child have any allergies?

*Does your child have any health conditions or special needs/restrictions?

*Physician's name

*Physician's Telephone number (xxx-xxx-xxxx)

*Authorization for treatment of a minor (Fill in your name)

My child/children listed above have my permission to participate in all the activities of the WNL ministry at First Presbyterian Church. I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the person listed on this form. In the event I cannot be reached or the alternate contact person cannot be reached in an emergency I hereby give my permission to the physician or dentist selected by the activity leader (acting as agent/representative for First Presbyterian Church) to hospitalize, to secure medical treatment and/or emergency medical transport for my child as deemed necessary.

Photo Release (please fill in your name)

I give permission for my child’s photograph to be taken during WNL events and used for internal publicity purposes and FPC church publications (including our weekly email newsletter and the church website).