Riverwood Community Church

Kids Bible Camp Registration 2010

Child's Last Name
Child's First Name
Street Address
City	State
Zip Code
Phone
E-mail
Home Church
Child's Date of Birth	Month January February March April May June July August September October November December   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year Year 1997 1998 1999 2000 2001 2002 2003 2004 2005   *MUST be age 4 as of 12/1/09
Grade Completed as of 6/2010	Grade Pre-K Kindergarten 1st 2nd 3rd 4th 5th
Parent Name	Relationship to Child  Mother Father Other
Please list any developmental, emotional, or physical challenges (including allergies):
Friend Request for Crew:
Emergency Contact #	Name and relationship to child?
Authorized to be picked up by:	1.  2.    3.
Do you authorize Riverwood Community Church to use images of your child from High Seas Expedition?	Yes No
For security purposes, please type the following letters exactly as you see them: JEsUs