FALL 2017/2018 WNL REGISTRATION FOR CHILDREN/YOUTH

Fall Semester:  Classes will begin on September 6th through November 15th with Fall Break week off.

Winter Semester:  Classes will begin on January 10th through March 21st with Spring Break off.
What is the cost per semester?  2, 3, 4 year OLD:  $40/child
K-High School:  $50/child with a family maximum of $125.
Free nursery for children under 2.
Payment is due with registration or on the first night of WNL.
Please complete a separate form for each person 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

*City/Zip

*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 con- tact immediately the person listed on this form. In the event I cannot be reached or the alter- nate 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 Pres- byterian Church) to hospitalize, to secure medical treatment and/or emergency medical trans- port for my child as deemed necessary.

*Photo Release (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 First Word and the church website).