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 PDTAdventure Club Registration Form Uploaded by Joshua Comstock - webmaster@kootenai.church IP 64.98.26.37
August 18, 2021 3:30 pm PDTDiane 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 PDTDiane 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 PDTDiane 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 PDTDiane 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 PDTDiane 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 PDTDiane 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 PDTDiane 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 PDTDiane 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 PDTDiane 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 PDTDiane 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 PDTDiane 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 PDTDiane 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 PDTDiane 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 PDTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:55 pm PDTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:56 pm PDTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 3:57 pm PDTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 4:00 pm PDTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 4:01 pm PDTDiane Rich - dianeErich@gmail.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 4:02 pm PDTJosh Comstock - josh@josharlahld.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 4:10 pm PDTJosh Comstock - josh@josharlahld.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 4:14 pm PDTDiane 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 PDTDiane 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 PDTMarcia Whetsel - secretary@nctv.com added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
August 18, 2021 4:15 pm PDTKathy Conger - secretary@kootenaichurch.org added by Joshua Comstock - media@kootenaichurch.org as a CC'd Recipient Ip: 216.244.82.210
July 19, 2022 4:32 pm PDTDiane 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 PDTMarcia 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 PDTKathy 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 PDTDiane 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 PDTMarcia 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 PDTKathy 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 PDTDiane 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 PDTMarcia 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 PDTKathy 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 PDTDiane 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 PDTMarcia 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 PDTKathy 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 PDTAC 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 PDTKathy 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 PDTAC 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 PDTKathy 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 PDTAC 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 PDTKathy 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 PDTAC 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 PDTKathy 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 PDTAC 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 PDTKathy 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 PDTAC 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 PDTKathy 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 PDTAC 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 PDTKathy 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 PDTAC 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 PDTKathy 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 PDTAC Crew - ac@kootenaichurch.org added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37
July 15, 2023 5:34 pm PDTKathy Conger - kathy.conger@kootenai.church added by Joshua Comstock - webmaster@kootenai.church as a CC'd Recipient Ip: 64.98.26.37