Backyard Bible Club Registration

Please complete all fields below to register:

Child's Name

Parent/Guardian Name:


(street address, city, state, and zip code)

Home Phone:

Work Phone:

Cell Phone:


Child's Birthdate:

Last grade completed in school:

Medical Information:

Medical or other information we need to know (Please include any known food allergies)

Emergency Contact 1:

Name & Phone #:

Emergency Contact 2:

Name & Phone #:

Dismissal Information:

Who may pick up your child at the end of each Club day?

Other Information:

Does your child attend Sunday School? If so, where?

May we have permission to photograph your child?

May we have permission to use your photographs that include your child for our promotional materials?

Which Club are you registering for?: