Wednesday Night Program

We have felt led by God to hold off on our Wednesday night kid’s program for the 2020 Fall Semester. We will reassess for the Spring Semester.

Name *

First

Last

Parent(s) Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Emergency Contact (non-parent)

Emergency Contact Phone #

Child #1 Name

Grade

Medical Conditions/Allergies we should be aware of?

Child #2 Name

Grade

Medical Conditions/Allergies we should be aware of?

Medical Release: *

I give my permission for DBC volunteers to administer basic first aid to my child(ren) in the event of an injury. I understand the staff will contact emergency services in the event of a significant injury.

Name