Registration for ARK

(1) Childs Full Name *
Date of Birth *
Age *
Grade In School *
(2) Child's Full Name
Date of Birth
Age
Grade In School
(3) Child's Full Name
Date of Birth
Age
Grade in School
(4) Child's Full Name
Date of Birth
Age
Grade In School
Parent/Guardian Name *
Address *
Phone # *

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Email
Emergency Contact *
Emergency Phone # *

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Church Affiliation
Permission to walk to
Saint John after school?
*
 Yes 
 No 
Permission to walk home
from Saint John after Ark?
*
 Yes 
 No 
Permission to use photographs or videos of my child(ren) on TV or webpage? (Names will not be posted) *
 Yes 
 No 
Please list any food allergies/health issues. (We will be serving a light snack at the beginning of the class)
For Parents/Guardian, please indicate if you would be willing to help at ARK.
 Yes 
 No 
I have a Middle or High School student who would be willing to help.
 Yes 
 No 
Student's Name (First/Last)
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If you have any questions, please contact our Office Administrator at 563-872-5849