New Destiny Worship Center

Children’s Ministry Registration

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Family Information:
Family Last Name:*
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone:*
Email 1:*
How many children will you be registering?*
Persons authorized to pick my child up:
Name
First Last
Name
First Last
Name
First Last

Child #1
Name
First Last
Birth Date
Grade
Gender
- Male
- Female
Does your child have any allergies, special needs or other medical needs?
- Yes
- No
Allergies
List all that apply
Special Needs
Other medical needs

Child #2
Name
First Last
Birth Date
Grade
Gender
- Male
- Female
Does your child have any allergies, special needs or other medical needs?
- Yes
- No
Allergies
List all that apply
Special Needs
Other medical needs

Child #3
Name
First Last
Birth Date
Grade
Gender
- Male
- Female
Does your child have any allergies, special needs or other medical needs?
- Yes
- No
Allergies
List all that apply
Special Needs
Other medical needs

Child #4
Name
First Last
Birth Date
Grade
Gender
- Male
- Female
Does your child have any allergies, special needs or other medical needs?
- Yes
- No
Allergies
List all that apply
Special Needs
Other medical needs

Child #5
Name
First Last
Birth Date
Grade
Gender
- Male
- Female
Does your child have any allergies, special needs or other medical needs?
- Yes
- No
Allergies
List all that apply
Special Needs
Other medical needs

Emergency Information:
Name*
First Last
Relationship*
Phone:*
Acknowledge
It is our desire to meet all the required needs and accommodations of your child(ren) to fulfill our mission, to teach a generation of children about our Lord and Savior Jesus Christ; baptizing them in the name of Jesus and preparing them to be disciples in God’s Kingdom.
Signature*
First Last
Date

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