| First name |
| Last name |
| Grade or age |
| Street address |
| Town, State & Zip |
| phone |
| parents' names |
| Church affiliation |
| Special needs (allergies; pick-up arrangements; etc.) |
| Referred by: |
| Attended last year |
| Registered this year |
| First Name | Last Name | Age/Grade |
| . | . | . |
| Street Address | . | Phone |
| Town, State, Zip | . | Emergency phone: |
| Allergies staff needs to know about: | . | |
| Parent signature: | . | |
| Joe Jones Grade 2 | Sue Jones Grade 4 | John Smith 4 years |
| Sally Smith Grade 1 | Bill Smith Grade 5 |
