Student's Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Student's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent #1 Name

First Name

Last Name

Phone

(###)

###

####

Parent #2 Name

First Name

Last Name

Phone

(###)

###

####

Sibling's Name

First Name

Last Name

Sibling's Name

First Name

Last Name

Sibling's Name

First Name

Last Name

Dismissal Information *

Do not dismiss my child until a parent or guardian picks them up.

Dismiss my child at the conclusion of class. An adult does not need to be present.

Photo Release *

I hereby authorize Marlton United Methodist Church (MUMC) to publish any photographs taken of me and/or my children for use in the MUMC printed publications, website, and social media.

Yes

No