REGISTRATION FORM Child's Name* First Last Child's Birthdate MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberEmail* Who is authorized to pick up your child? (Must be at least 18 years old)If needed, would you like for our nursery workers to change your child's diaper?* Yes No We provide water and crackers during the program. Is that okay?* Yes No Any allergies, special needs, or extra information? Name of Person Filling Out the Form* First Last I am giving my consent for Grace Church to use on their website or in print media all photographs in which I/my child appear(s) while involved in the ministries of Grace Church.* I Agree Questions or Comments
