KIDS DIGITAL REGISTRATION FORM: ONE

Child Name *

First

Last

Birthdate *

Grade *

Nursery (birth-2 years old)
Preschool (3-4 years old)
Pre-K (4 years or older by Sept. 1-going into Kindergarten the next school year.)
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade

School

Does your child carry an EPI pen?

Medical History

ADD/ADHD
Asthma
Autism
Cardiac Problems
Diabetes
Wears glasses
Other

If "other," please describe, also list allergies/dietary restrictions:

Parent/Guardian Name(s) *

Parent/Guardian Email *

Parent/Guardian Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian Cell Phone (include name if more than 1 number) *

Parent/Guardian Cell Phone (include name if more than 1 number)

Emergency Contact (other than parent/guardian) *

Emergency Contact Phone Number *

List of individuals who are allowed to pick up your child including immediate family. *

Health Insurance Company & Policy Number

MEDICAL RELEASE: In the event of accident, injury, or illness, I authorize any and all medical attention necessary to be administered to my child, listed above, under the direction of such medical professionals as the Church determines appropriate under the circumstances. Please print your signature below: *

WAIVER: By sending my child to Sewickley Presbyterian Church (SPC) events, I agree to indemnify and hold harmless Sewickley Presbyterian Church, its staff, volunteers, or anyone affiliated with SPC, from any liability for an accident or injury which may be incurred. Please print your signature below: *

Todays' Date: *

Church Office Hours

Monday-Friday:

Saturday: Closed

Sunday: Closed

Locate Us

414 Grant Street
Sewickley, PA 15143
412.741.4550

Newest Newsletter

Facebook
Instagram
Youtube

KIDS DIGITAL REGISTRATION FORM: ONE

Church Office Hours

Locate Us

Newest Newsletter

Church Member Log-In

Employment Opportunities

Deacon Resources

SPC Blog