First United Methodist Church

Phone: 386-677-3581 | 336 South Halifax Drive Ormond Beach, FL 32176

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Children's Event Registration

Event:

Child Name: *

Child Email:

Child Birth Date: *

Gender: *

Grade: *

Please check the grade currently attending or if registering for a summer event then the grade child will be attending in the upcoming school year.

Known Allergies or Medical Conditions:

Home Address *

Street Address


City	State	Zip

Home Phone #:

Please fill in the information of the child's parents and/or legal guardians. The information of at least one parent/guardian must be filled.

Mother's Name:

Mother's Email:

Mother's Work Phone #:

Mother's Cell Phone #:

The mother lives at a seperate address

Father's Name:

Father's Email:

Father's Work Phone #:

Father's Cell Phone #:

The father lives at a seperate address

Other Guardian Name:

Other Guardian Email:

Other Guardian Work #:

Other Guardian Cell #:

The other guardian lives at a seperate address

Emergency Contact

Name: *

Home Phone: *

Cell Phone:

Relationship:

Who Will Pick Up Child/Student?

Name: *

Home Phone: *

Cell Phone:

Relationship:

Home Church:

Child T-Shirt Size:

ONLY if event description above states t-shirts will be provided.

Adult T-Shirt Size:

ONLY if event description above states t-shirts will be provided.

Your Comments:

Please Enter the Security Code Shown Below:

Genesis Counseling Center

Phone: 386-677-3581 | 336 South Halifax Drive Ormond Beach, FL 32176
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