Child Enrollment Form
* Required
Child's Name
*
Date of Birth (mm/dd/yyyy)
*
Grade Completed
*
Any Allergies? (esp. food)
Parent(s) Name(s)
*
Email
*
Address
*
City
*
State & Zip
Home Phone
* numbers only, no dashes, spaces or decimals
Example: 7045551212
Providence Baptist Church Member?
Yes
No
If "No", may we ask what church you attend?
Emergency Contact (other than parent)
*
Phone
* numbers only, no dashes, spaces or decimals
Relationship to Child?
*
Illness/Activity Restrictions?
Child's Physician
Physician Phone
Friend to place your child with? (If possible)
Questions & Comments?