Main Street Church of Brigham City  
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Solid Rock
 Kid'sClub:
Inside Out & Upside Down on Main Street!
REGISTRATION
Sunday, 1 April - Wednesday, 4 April  2012
5:00pm - 7:00 pm
Open to Children 4 years old - 5th Grade
Parent/Legal Guardian Name:
 (*Required)
Child #1 Name (First & Last)
 (*Required)

Currently in:
Age:       

Child #2 Name (First & Last)

Currently in:
Age:       

Child #3 Name (First & Last)

Currently in:
Age:       

**If you are registering more than three children, please fill out and submit this form with the first three children, and then return and fill out the form again for any additional children.**
Street Address
 (*Required)
City, State & ZIP
 (*Required)
Home Phone:
 (*Required)
Cell Phone:
 (*Required)
(If no cell phone, write "no cell")
Your E-mail:
 (*Required)
Emergency Contact Name & Phone:
 (*Required)
Church affiliation (optional):
Please specify any allergies or special needs your child(ren) may have:
Choose one:
 My Child(ren) will:

Be picked up at the church
Walk home
Required:
 By checking this box, I am declaring that I am the parent or legal guardian listed above, and I give my child(ren) permission to attend the Kids' Club "Inside Out & Upside Down on Main Street", Sunday, April 1 - Wednesday, April 4, 2012, at Main Street Church, 48 North Main St., Brigham City, Utah. I authorize Main Street Church personnel to obtain emergency medical care if I cannot be reached immediately.
Required:
 I understand that photos may be taken (by authorized adult leaders) of the activities, which may include my children. Some of these photos may be displayed on the Main Street Church website, or church slide show, or in other materials that may promote future events such as this. By allowing my child to participate, I am giving my permission for these photos to be taken and used.*

(*If there are reasons for which it is not desirable for your child(ren) to be photographed, you will need to discuss this with Karen Holder prior to registration.)
   
 

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Main Street Church of Brigham City
©2012 by Main Street Church of Brigham City
(Formerly Living Hope Christian Fellowship)
www.mscbc.org

48 North Main Street    •    Brigham City, Utah  84302
Tel: (435) 723-6469   •    Fax: (435) 921-0426
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Main Street Church is a member church of the
Northern Utah Ministerial Association (NUMA).
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