Christ Kids Wednesday Nights Fall 2024

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Child's Name

Birthdate

Gender

Please select one option.

Male Female

Grade 24/25

Please select all that apply.

Pre-K Kindergarten 1st 2nd 3rd 4th 5th 6th

School your child attends

*

Allergies/Concerns

Parent 1 Name

*

Parent 1 Phone

*

Parent 1 Email

*

This address will receive a confirmation email

Parent 2 Name

Parent 2 Phone

Parent 2 Email

Emergency Contact Name

*

Emergency Contact Phone

*

Registration Fee goes towards providing meal

Registration Fee ($45) Pre-Approved Partial Scholarship ($25) Pre-Approved Scholarship ($0)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

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