Name of Parent/Guardian *

First Name

Last Name

Cell Phone *

Guardian contact numbers may be included on your child's class list

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

By registering my child(ren) for KIDS' Club, I give my consent for University Avenue Baptist Church to use my child's photographs and video footage in church promotion, publicity, and website. *

I Do

I Do Not