Knollwood Baptist Church

Crash Class Registration Form

(please print)

Child's Name _________________________________

Street Address ________________________________

City ________________________________

Postal Code _____________________________

Phone # (______)________________________

Birth Date ____________/______/_________

School Grade ____________________________

Food allergies or health concerns: Yes ______ No ______

If yes please specify:__________________________________

Parent or Guardian Name ______________________________

Do you wish for your child to remain in the classroom for you to pick

up following the service? Yes ______ No ______

If you yourself are not picking up the child and have designated

someone else, please state name of person _________________________

Note: By stating No you are aware that the responsibility of

of your child's welfare is on the person whom you have assigned.

Is there any other information we should know regarding your

child? ___________________________________________

Signature ______________________________ Date_______________

Thank you for your registration.  Return completed form to mail box D-1 or give it to Cathy Koski