All fields with an "*" must be filled out below before pressing the submit button.

*Child's First Name:
*Child's Last Name:
Nick Name:
*Street Address:
*City/State/Zip:

*Male/Female:	Male Female	*Telephone(Home):
*Grade/Age entering in fall:	2 Yr Old 3 Yr Old 4 Yr Old K 1st 2nd 3rd 4th 5th 6th 7th 8th	*Date of Birth:

*In case of emergency, contact name:
*Emergency Contact Phone:
Mother's/Guardian Name
Mother's/Guardian Phone:
Father's/Guardian Name:
Father's/Guardian Phone:

Allergies or other medical conditions:

Special Education needs:

Home Church:

If attending with a non-member friend, please list the friend's name:

I/we, parent/guardian of , give Grace Lutheran Church permission to use photographs and/or video of my child(ren) for ministry promotional purposes. I understand that promotional photographs and names of those pictured may be submitted to local newspapers or used on Grace Lutheran Church's Web site for publicity purposes.
Waiver
By registering online, the undersigned here by agrees that they shall hold harmless Grace Lutheran Church, 1300 Kishwaukee Valley Road, Woodstock, Illinois and all its agents from any legal action or discourse that may arise from any and all accidents or injuries that may occur to the undersigned while engaging in athletic activities on the premises of Grace Lutheran Church for the period beginning July 2011.
(I understand that by registering online I am giving my consent for Grace’s photograph/video/PR purposes and agree to the waiver information)

*Contact Person Name
*e-mail address:
Please enter the text from the image: