Student's Name (required)

Student's Nickname

Student's Gender (required)

Student's Date of Birth

Grade Completed (required)

Food Allergies

Other Allergies

Additional Medical Information

Parent/Guardian's Name (1) (required)

Parent's Phone Number (1) (required)

Parent's Address (1) (required)

Parent/Guardian's Name (2)

Parent's Phone Number (2)

Parent's Address (2)

Church affiliation

Emergency Contact(s) (Name and Phone #) During Activity Hours (required)

I grant to employees and volunteers of the New Cumberland Church of the Nazarene, New Cumberland, the right to take photographs of my child in connection with church-sponsored events and activities. I authorize the New Cumberland Church of the Nazarene, to use and publish the same in print and/or eletronically. I agree that New Cumberland Church of the Nazarene, New Cumberland may use such photographs of my child with or without any child's name and for any lawful purpose, such as publicity, illustration, adverising and web content.

Parent statement (required)
I grant/agree with the above statement.

Your Name (required)

Your Email (required)

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