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Kid's Ministry PitStop Wednesdays

Parent/Guardian 1 information
*1st Parent/Guardian - First Name:
*1st Parent/Guardian - Last Name:
*Phone Number:
*Email:
*Emergency Contact Number:
*Street Address:
*City:
*Zip Code:
*Will the parent/guardian be staying at the church for adult activities?:
If "Yes", where will you be for contact purposes?:
Please fill out information if there is a second parent/guardian
2nd Parent/Guardian First Name:
2nd Parent/Guardian Last Name:
2nd Parent/Guardian - Phone Number:
2nd Parent/Guardian - Email :
2nd Parent/Guardian Street Address:
2nd Parent/Guardian City:
2nd Parent Guardian Zip Code:
Please provide information for a 1st child you are registering
*First and Last Name:
*Age:
*Grade:
*Birthdate:
Allergies/Alerts (Please Describe) - Child 1:
Please provide information for a 2nd child you are registering
First and Last Name - Child 2:
Age - Child 2:
Grade - Child 2:
Birthdate - Child 2:
Allergies/Alerts (Please Describe) - Child 2:
Please provide information for a 3rd child you are registering
First and Last Name - Child 3:
Age - Child 3:
Grade - Child 3:
Birthdate - Child 3:
Allergies/Alerts (Please Describe) - Child 3:
Please provide information for a 4th child you are registering 
First and Last Name - Child 4:
Age - Child 4:
Grade - Child 4:
Birthdate - Child 4:
Allergies/Alerts (Please Describe) - Child 4:
Please provide information for a 5th child you are registering 
First and Last Name - Child 5:
Age - Child 5:
Grade - Child 5:
Birthdate - Child 5:
Allergies/Alerts (Please Describe) - Child 5:
Please provide information for a 6th child you are registering 
First and Last Name - Child 6:
Age - Child 6:
Grade - Child 6:
Birthdate - Child 6:
Allergies/Alerts (Please Describe) - Child 6:
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