2PK Kids Registration

PDF Version available here.

Parent/Guardian Information

Last Name of Family:

Primary Contact:

Parent/Guardian #1

Name:

Relationship to Child:

Primary Phone:

Does this phone number receive texts?

Yes

Email Address:

Street Address:

City:

State:

Zipcode:

Parent/Guardian #2

Name:

Relationship to Child:

Primary Phone:

Does this phone number receive texts?

Yes

Email Address:

Street Address:

City:

State:

Zipcode:

Child Information

Child #1

First Name:

Last Name:

Preferred Name:

School:

Grade:

Birthdate:

Emergency Contact Information

Emergency contact (other than parent):

Phone Number:

Relationship:

Please initial each statement and sign below:

In the event that my child has a medical emergency and I am unable to be reached, Second Presbyterian Church staff may obtain and authorize medical treatment for my child.

Second Presbyterian Church may use my child’s name and/or picture in photos and video promotional materials regarding Second Presbyterian Church.

Parent/Guardian Signature:

Date: