BKC Registration 2009

Please complete the following form then press the Submit button. You may register up to five children per registration form. A copy of your completed registration form will be emailed to the email address you provide below.

Parent/Gaurdian Information
First Name:
Last Name:
Street Address:
City, State & Zip:
Home Phone:
Work or Cell Phone:
Email:
Child Information
Child 1
Child 1 - First Name:
Child 1 - Last Name:
Child 1 - School Name:
Child 1 - Grade Going Into Fall 2009:
Child 1 - Allergies/Medical Conditions:
Child 2
Child 2 - First Name:
Child 2 - Last Name:
Child 2 - School Name:
Child 2 - Grade Going Into Fall 2009:
Child 2 - Allergies/Medical Conditions:
Child 3
Child 3 - First Name:
Child 3 - Last Name:
Child 3 - School Name:
Child 3 - Grade Going Into Fall 2009:
Child 3 - Allergies/Medical Conditions:
Child 4
Child 4 - First Name:
Child 4 - Last Name:
Child 4 - School Name:
Child 4 - Grade Going Into Fall 2009:
Child 4 - Allergies/Medical Conditions:
Child 5
Child 5 - First Name:
Child 5 - Last Name:
Child 5 - School Name:
Child 5 - Grade Going Into Fall 2009:
Child 5 - Allergies/Medical Conditions:
Emergency Contact Information
First & Last Name:
Phone:
Relationship to Child:
Club Location and Times
Choose a location/time that best fits your needs:
Clubs:
9:00am - 10:30am: Bill & Vicky Farley: 0N649 Delano St., Wheaton. Near PHCC
10:45am - 12:15pm: Joel and Rhonda Sisson: 0N711 Courtney Lane; Winfield
1:30pm - 3:00pm: Marian Park Apartments: 2126 W. Roosevelt Wheaton (M, T, Th, F)
Note: If you are registering more than one child and would like to attend multiple locations, please indicate in Special Notes below.
Additional Information
What Church Do You Attend?:
Special Notes: