Faith Presbyterian Church

2012 Summer Reading & One-Cent Movie Registration Form

Summer Reading Registration

Student's Name (required)
Entering Grade (required)
School (required)
The dates of the reading program are as follows: June 9, June 16, June 23, and June 30.
Do you plan for your child to attend all dates? If not, which dates will your child miss: (required)
Parent or Gardians Name (required)
Address (required)
Home Phone Number (required)
Work Phone Number
Cell Phone Number
Email Address (valid email required)
Emergency Contact (required)
Emergency Contact Phone (required)
Persons authorized to pick child up (ID's will be checked) (required)
Please list any known allergies or medical concerns
By checking the box below, I, the undersigned parent/gaurdian, do herby grant permission for my son/daughter/ward to receive neccesary first aid anr/or medical treatment in the event of an injury or illness while attending the Free Summer Reading program sponsored by Faith presbyterian Chuch, and I accept responsibility for the full payment for such medical treatment. I herby hold Faith Presbyterian Church and their representatives harmless in the exercise of this authority.
I agree to the above