Student Master Registration

Student Master Registration
2011-2012 School Year

Child's Name		Birthdate
School Attending		Grade
Baptism Date		My child has not been baptized yet
Child resides with both parents mother father guardian

PARENT INFORMATION

Father's Name		Home Phone
Address		Work Phone
City, St, Zip		Cell Phone
Preferred Email
Preferred Methods of Communication
Email Post Mail (check one)	Home Phone Cell Phone (check one)

Mother's Name		Home Phone
Address		Work Phone
City, St, Zip		Cell Phone
Preferred Email
Preferred Methods of Communication
Email Post Mail (check one)	Home Phone Cell Phone (check one)

Emergency Contact (other than parent)
Name	Phone

In the event of an emergency, where medical treatment is required, I give my permission to the church staff or an adult supervisor to obtain the services of a licensed physician for my child. Please attempt to notify me immediately concerning such an emergency.

I give permission for my child's picture to be used in marketing publications, including the Vinje Website, brochures, posters.

Parent Name (in lieu of signature) Date

Is there anything our staff and volunteers should know about your child?
Please list all allergies My child carries an Epi-pen
Other important health issues

Please register my child for the following programs and activities (check all that apply)

Little Vinje Village (ages 3-Kdg)	Joyful Kids Choir (grades 3-6)
Vinje Village (grades 1-5)	WOW Wednesdays (grades 3-5)
Little Saints Choir (grades K-2)	NOVA choir (grades 6-8)

Image verification

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