Wednesday Night Ministries Registration 2010-2011

To register;   Please fill out this form and click on the Submit button,

Questions, contact Diana Streckfuss or Donna Beal at 333-4444.

Times: 6:00-7:00 p.m.   Locations - Please Choose the one you will regularly attend.
East Campus (114th & Center)
West Campus (180th & Dodge)

Placement guidelines: Pre1 b-day 4/15/06-10/15/07; Pre2 b-day 10/15/05-4/14/06; Kind. Born before 10/15/05
1. Student Information
Name
Birthdate   Age   Sex   Grade
Member of LCM?   Yes   No
Medic Alert?   Yes   No   If yes, explain
Student baptized   Yes   No

2. Student Information
Name
Birthdate   Age   Sex   Grade
Member of LCM?   Yes   No
Medic Alert?   Yes   No   If yes, explain
Student baptized   Yes   No

3. Student Information
Name
Birthdate   Age   Sex   Grade
Member of LCM?   Yes   No
Medic Alert?   Yes   No   If yes, explain
Student baptized   Yes   No

4. Student Information
Name
Birthdate   Age   Sex   Grade
Member of LCM?   Yes   No
Medic Alert?   Yes   No   If yes, explain
Student baptized   Yes   No
Please list any siblings under 3 years old/over 5th grade:


Parent/Guardian Information
Parent/Guardian Name(s)
Address
City   State   Zip Code
Phone   Cell   E-mail
Members of LCM?   Yes   No
Would you like information about becoming a member?   Yes   No

* We invite you to be a part of our ministry.  Please indicate area(s) you would like to volunteer for:
  Leader     Grade preference?   1st Choice   2nd Choice   3rd Choice
  Substitute / Helper      Children & Family Ministry Team
  Meal set up / clean up      Special Programming (Christmas Program, VBS)