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Wacky Wednesday Registration
First United Methodist Church
66 Harrison Ave
Franklin, NC 28734
www.firstumcfranklin.org
Participant Information
First Name
*
Last Name
*
Sex
*
M
F
Birth Date
*
Grade Completed
*
4 Years
5 Years
Kindergarten
1st
2nd
3rd
Phone Number
*
Child will attend
*
June 18
June 25
Mystery Trip on June 26 (4th/5th Grade only)
Is there anything you want us to know about your child
*
Do you have allergies to:
*
NA
Pollens
Medications
Foods
Insect Bites
Other
Other
Do you suffer from or have experienced:
*
NA
Asthma
Epilepsy/Seizures
Heart Trouble
Diabetes
Frequent Upset Stomach
Physical Handicap
Does child wear:
*
NA
Glasses
Contacts
Dental Appliance
For your safety and our knowledge, are you a :
*
Good Swimmer
Fair Swimmer
Non-swimmer
Medical Concerns Or anything we need to be aware of :
*
Date of last tetanus shot:
*
Please list and explain any major illnesses experience during the last year:
*
Family Doctor (Include phone) :
*
Medical Insurance Company:
*
Policy Number:
*
My child may be identified and/or photographed and/or videotaped during Children's ministry activities
*
Yes
No
Pictures may be used on our website to communicate activities
*
Yes
No
Household / Adult Primary Contact
Relationship to Participant:
*
First Name
*
Last Name
*
Address 1
*
City
*
State
*
Zip
*
Phone
*
Alternate Phone
Email Address
*
Emergency Contact
(other than parent)
:
*
Emergency Phone:
*
PLEASE be sure to print off the consent form with your signature & return to the office.
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