Community Kids Registration Form

Child's Name

Child's Address

Child's Birthday

Gender

Male Female

School

Grade

Does the Child Reside in the West York School District?

Yes No

Parent/Guardian's Name

Parent/Guardian's Phone

Parent/Guardian's Email

This address will receive a confirmation email

Parent/Guardian's Address

Emergency Contact Name

Emergency Contact Phone

Mode of Transportation

Bus Car Walk

Who Will Pick-up: (First and Last Name as it Appears on Government Issued ID)

Any Allergies (Please Explain):

Any Health Issues or Learning Disabilities (Please Explain):

Standards of Student Conduct

We value and protect all students and will defend the safety and peaceful environment of everyone.

No bullying.

Show respect for leaders and fellow students.

Follow instructions.

No personal cell phones/technology are permitted in the classroom.

No destruction of property.

No lewd language or behavior is permitted.

Pathway Community Church Kids Club reserves the right to suspend any student participation based on violation of anything listed above at our discretion.

Will You Support The Standards of Student Conduct

Yes No

Additional Notes:

Other Children From Your Household Attending the Program: (A Separate Registration Form is Required for Each Child)

Do you give Pathway Community Church* authorization to use photographs, video or audio containing your child for public and promotional use including but not limited to: Websites, Social Media, Training Conferences/Presentaions, Printed Promotional Materials, etc. (Any media containing your child will not be sold or used outside of Pathway Community Church and their ministries. *Community Kids After School Program is owned and operated by Pathway Community Church.)

Yes No

Please provide payment below. Completion of this registration form does not guarantee placement or acceptance into the program. Upon review of your registration, you will be notified of acceptance or rejection and will receive an email with further details.

Note: Limited Spots Are Available.

Non-Refundable Registration Fee (One Payment Required per Child) $10

Phone

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Community Kids Registration Form

Description

Please Fix the Following