Adventure Club Registration Form


Parents: Please fill out the following registration form.

 

Name of Child: Gender:  Age:  DOB:  

Name of 2nd Child: Gender:  Age:  DOB:  

Name of 3rd Child: Gender:  Age:  DOB:  

Name of 4th Child: Gender:  Age:  DOB:  

Name of 5th Child: Gender:  Age:  DOB:  

Mailing Address:  

City: ST: Zip:  

Email Address:

Main Phone:   Alternate Phone:  

Parent/Guardian Names: Home Church:  

 

Emergency contacts if parents cannot be reached:

Name: Relationship to child:  
Phone:  

Name: Relationship to child:
Phone:  

 

I authorize the following individuals to pick up my child(ren) from Adventure Club at Kootenai Community Church:

OR; complete at least one of the following:

Relationship to child:  

Relationship to child:  

Relationship to child:  

 

ONCE YOU SIGN THIS FORM AND SUBMIT, YOU WILL BE REDIRECTED TO A PAGE TO COMPLETE FOR PARENTAL CONSENT.

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Adventure Club Registration Form
lock iconUnique Document ID: 900d99c5e92d6a311387dda5ebf6bbdb801a2cdf
Timestamp Audit
August 18, 2021 3:23 pm PSTAdventure Club Registration Form Uploaded by Joshua Comstock - webmaster@kootenai.church IP 64.98.26.37
August 18, 2021 3:30 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:30 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:31 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:32 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:33 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:34 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:34 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:35 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:36 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:38 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:40 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:41 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:53 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
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August 18, 2021 4:00 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
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August 18, 2021 4:14 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 4:15 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 4:15 pm PSTMarcia Whetsel - secretary@nctv.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
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July 19, 2022 4:32 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 69.36.160.153
July 19, 2022 4:32 pm PSTMarcia Whetsel - secretary@nctv.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 69.36.160.153
July 19, 2022 4:32 pm PSTKathy Conger - secretary@kootenaichurch.org added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 69.36.160.153
July 19, 2022 4:44 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 69.36.160.153
July 19, 2022 4:44 pm PSTMarcia Whetsel - secretary@nctv.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 69.36.160.153
July 19, 2022 4:44 pm PSTKathy Conger - secretary@kootenaichurch.org added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 69.36.160.153
July 19, 2022 5:18 pm PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 69.36.160.153
July 19, 2022 5:18 pm PSTMarcia Whetsel - secretary@nctv.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 69.36.160.153
July 19, 2022 5:18 pm PSTKathy Conger - secretary@kootenaichurch.org added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 69.36.160.153
July 13, 2023 10:10 am PSTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 24.143.0.169
July 13, 2023 10:10 am PSTMarcia Whetsel - secretary@nctv.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 24.143.0.169
July 13, 2023 10:10 am PSTKathy Conger - secretary@kootenaichurch.org added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 24.143.0.169
July 13, 2023 10:20 am PSTAC Crew - ac@kootenaichurch.org added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 24.143.0.169
July 13, 2023 10:20 am PSTKathy Conger - kathy.conger@kootenai.church added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 24.143.0.169
July 15, 2023 4:50 pm PSTAC Crew - ac@kootenaichurch.org added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 4:50 pm PSTKathy Conger - kathy.conger@kootenai.church added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 4:52 pm PSTAC Crew - ac@kootenaichurch.org added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 4:52 pm PSTKathy Conger - kathy.conger@kootenai.church added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 4:58 pm PSTAC Crew - ac@kootenaichurch.org added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 4:58 pm PSTKathy Conger - kathy.conger@kootenai.church added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 5:19 pm PSTAC Crew - ac@kootenaichurch.org added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 5:19 pm PSTKathy Conger - kathy.conger@kootenai.church added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 5:20 pm PSTAC Crew - ac@kootenaichurch.org added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 5:20 pm PSTKathy Conger - kathy.conger@kootenai.church added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 5:29 pm PSTAC Crew - ac@kootenaichurch.org added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 5:29 pm PSTKathy Conger - kathy.conger@kootenai.church added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 5:33 pm PSTAC Crew - ac@kootenaichurch.org added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 5:33 pm PSTKathy Conger - kathy.conger@kootenai.church added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 5:34 pm PSTAC Crew - ac@kootenaichurch.org added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
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