Kids Remix Summer Fix - St Luke Baptist Church

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Child's Name*
First Last
Child's Age*
Child's Birthdate*
Date Format: MM slash DD slash YYYY
Child's Grade
Parent/Guardian's Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Parent/Guardian's Contact Number*
Alternate Contact Number
Parent/Guardian's Email
Allergies (please list for each child)
Signature*
Sign the form using your mouse or using a stylus or finger if signing on mobile device
Registration Fee (covers all children living in the household)*
Price: $25.00 Quantity:
Total
$0.00
Date
Date Format: MM slash DD slash YYYY