Registration for ARK
2019-2020 Registration for Ark
(1) Childs Full Name
*
Date of Birth
*
Age
*
Grade In School
*
Please select
K
1st
2nd
3rd
4th
5th
(2) Child's Full Name
Date of Birth
Age
Grade In School
Please select
K
1st
2nd
3rd
4th
5th
(3) Child's Full Name
Date of Birth
Age
Grade in School
Please select
K
1st
2nd
3rd
4th
5th
(4) Child's Full Name
Date of Birth
Age
Grade In School
Please select
K
1st
2nd
3rd
4th
5th
Parent/Guardian Name
*
Address
*
Phone #
*
###
-
###
-
####
Email
Emergency Contact
*
Emergency Phone #
*
###
-
###
-
####
Church Affiliation
Please select
Saint John Lutheran
First Presbyterian
Saint Joseph Catholic
Other
None
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