Child's
Name:

Date of Birth:      Age:

Address / PO Box:

City:   State:Zip:

Parents Name                                  

Phone #                                          Email

Medical Issues or Allergies: (indicate all that apply and explain if needed)

Medical Issue

Environmental Allergies

Food Allergies

Do you have a church home?                    If yes, where


Each session is limited to 18 children. Please indicate your first and second choice. If we are unable to enroll you in your first choice, we will enroll you in your 2nd choice. Families accepted into the Winter 2012 program will be notified by email as to which session they have been enrolled. If you do not have email, we will notify you by postal mail.




I agree to follow the Guidelines of the Kidz Gym program. I will attend weekly, except for illness or out-of-town family events. I will be responsible for my child’s safety at all times and insure that he/she does not jeopardize the fun and safety of other children. If an accident should occur, I will not hold Harvest Community Church responsible. I will indicate my agreement by checking and dating the boxes below.









                                         
Kidz Gym Registration Form
Winter 2012 Session
(Please submit one form for each child)
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(  Required)
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First Choice
Second Choice
Date
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I Agree