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 from Adventure Club at Kootenai Community Church:

Realtionship to child:  

Realtionship to child:  

Realtionship to child:  

 

Leave this empty:

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Signature Certificate
Document name: Adventure Club Registration Form
lock iconUnique Document ID: fe461da853437308a2c11d31d6c154b7ee21e725
Timestamp Audit
August 18, 2021 3:23 pm PDTAdventure Club Registration Form Uploaded by Joshua Comstock - media@kootenaichurch.org 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 3:30 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