| Child's Name: |
| Last Name*: | |
| First Name*: | |
| Child likes to be called: | |
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| Gender*: | M F |
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| Birth Date* (mm/dd/yyyy): | |
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| Grade as of September, 2009:*: | |
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| School: | |
Contact Information
Mailing Address |
| Street*: | |
| Apt. #: | |
| City*: | |
| State*: | |
| Zip Code*: | |
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| Child's Email: | |
Parent Information
Parent 1 |
| Name*: | |
| Email: | |
| Home Phone*: | |
| Work Phone: | |
| Cell Phone: | |
Parent 2 |
| Name*: | |
| Email: | |
| Home Phone*: | |
| Work Phone: | |
| Cell Phone: | |
Other Important Information
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| Special Needs, Allergies, Medications: | |
| Emergency Contact:* | |
| Relationship:* | |
| Phone:* | |
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| Pediatrician*: | |
| Phone: | |
Photography Permission
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Yes, I give Plymouth Church permission to use my child’s likeness and/or image for promotional purposes in print materials and digital media including the Plymouth Church web site. I understand that children in these images will not be identified by name.
No, I do not give permission.
Each member parent (Dad too!) is expected to volunteer a minimum of two times a year in support of Plymouth’s family programs. Please indicate which activities either parent would be interested in volunteering for (check as many as apply):
DiscoveryLand assistant teacher for your child's age group
DiscoveryLand assistant teacher for age group:
DiscoveryLand traffic guide/attendance collector
Sunday Gymnasium monitor (after the worship service)
Yankee Fair volunteer (November 2009)
Christmas Pageant volunteer (December 2009)
Vacation Bible Camp volunteer (August 2010)
Volunteer at Sunday special events (such as PumpkinLand, ValentineLand)
Volunteer at Saturday &/or evening special events (Easter Egg decorating, summer Playground Fun, movie night)
Information Table helper during Fellowship Hour (as needed for registration drives, volunteer sign-ups, etc.)
If you have questions or comments about DiscoveryLand and/or volunteer opportunities, please contact Julia Rassmann, Director of the Ministry to Families and Children, at the Church Office.
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