Do not press the ENTER key until you have entered all the information in the fields below.

iBLAST KIDS CLUB (Pre-K through 5th Grade) and iGNITE MIDDLE SCHOOL PROGRAM (6th through 8th Grade) start back up on Tuesday, October 3rd, 2017, at Christ Reformed Church.

Child's Full Name:


Child's Age:


Birth Date:


Boy/Girl:


Current Grade Level:


School My Child Attends:


Parent or Guardian's Name:


Home Address, City, State, Zip:


Home Phone:


Work Phone:


Cell Phone:


Email:


Home Church:


Emergency Pick-Up #1 Name:


Emergency Pick-Up #1 Phone:


Emergency Pick-Up #2 Name:


Emergency Pick-Up #2 Phone:


Food Allergies/Medical Concerns (provide details)?


I give permission for my child's photo, audio or video recording to be used to promote Good News Clubs:
Yes

Enter CLUBS to ensure proper registration: