Kid Life Registration Form

Please fill out this form and click submit.

Kid's Information

Full Name

*

Gender

*

Please select one option.

Male Female

Birthdate

*

Grade

*

Please select one option.

Pre-Kindergarten Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade

Name of School

Allergies

*

Please select one option.

Yes None

Allergies

Diapering

*

Please select one option.

Kid Life Staff may change my child's diaper Kid Life Staff should inform me when changing is needed My child does not require diapering

Are there any concerns or interests unique to your child that you would like to share to assist us in providing the best experience for your child?

Parent/Guardian Information

Primary Parent/Guardian

*

Relationship to Child

*

Parent/Guardian Phone

*

Parent/Guardian Email

*

This address will receive a confirmation email

Address

*

Child Check-out

In addition to yourself, who are you authorizing to pick up the child?

*

Authorized Individual's Phone

*

Emergency Contact (other than parent/guardian)

Emergency Contact Name

*

Emergency Contact Relation

*

Emergency Contact Phone

*

Photo/Video Authorization

I authorize New Life Lutheran to use photos or videos of my child for promotional use via social media, website, or published material.

Photo Release

*

Please select all that apply.

Yes No

I release all liability for injuries while participating in New Life activities

*

Please select all that apply.

Yes

Description

Please fill out this form and click submit.

Please Fix the Following

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