There is a $5.00 registration fee per child

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First Name: Last Name:

Grade Entering: Pre-K Kindergarten 1 2 3 4 5 6 7 8Date of Birth: 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 Address:

Address: City:

State: TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VA WA WV WI WYZip Code: Telephone Number:

Siblings: Yes NoName(s) and Age(s):

Parent(s) Name(s):

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Emergency Contact: Phone Number:

Allergies or Medical Conditions:

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Church Affiliation (Name and Location):

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