EmailMe Form - Kids Jam Registratiion Form

Child's Name*

First Last

Age*

Parent's/Guardian's Name(s)*

First Last

How many adults plan to attend any of the adult classes?

None

One

Two

Three

Address*

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone*

### - ### - ####

Email*

Emergency Contact Name

Emergency Contact Phone Number*

### - ### - ####

Relation to child

Child's/Children's Food Allergies (list)

Child's/Children's Medical Concerns

Church Home

Person(s) name(s) who may pickup the child*

Kids Jam leaders have permission to photograph/film the minor designated above?

Yes

No