Issuu on Google+

EPWORTH CHILDREN’S DAY OUT REGISTRATION FORM) Entrance Date____________ Preferred day ____________ 2nd choice ____________

For Office Use Only: Regis.Fee____________ Paid:_____ By________ Date:________

CHILD’S NAME_________________________________________________________ (Last)

(First)

(Middle)

(Name for Nametag)

Address________________________________________________________________ (Street)

(City)

(State)

Phone___________________________

(Zipcode)

Child’s Birthdate______________

Mother’s Name____________________________________ Address (if different)______________________Phone (if different)_____________ Employer Name___________________________Phone________________________ Address________________________________________________________________ (Street)

(City)

(State)

(Zipcode)

Father’s Name ___________________________________________________ (Address (if different)_____________________Phone (if different)_____________ Employer Name____________________________________Phone __________________ Address________________________________________________________________ (Street)

(City)

(State)

(Zipcode)

Parent email address to be used for CDO communications only____________________ Please give any information regarding the child’s physical, emotional, or social health which might be of value to the staff.________________________________ ________________________________________________________________________

Registration fee of $30 per child or $45 per family must accompany this form. Registration fee is not refundable. Make checks payable to Epworth United Methodist Church, Please note “CDO” in memo line.


Cdo%20registration%20form%202012