Step 1

Parent/Guardian 1

Parent/Guardian 2

Full Name_____________________________________

Full Name_____________________________________

Cell Phone____________________________________

Cell Phone____________________________________

Email________________________________________

Email________________________________________

Birth Date _____/______/______

Birth Date _____/______/______

Relationship to Child____________________________

Relationship to Child____________________________

Does this parent live at the address below Y / N

Does this parent live at the address below Y / N

List the name of others authorized to pick up your child_________________________________________________
____________________________________________________________________________________________

Step 2 Address Information (primary residence of child)
Home Address_________________________________________________________________________
City_____________________________ State_______ Zip__________ Phone_____________________

Step 3 Individual Kid’s Information
First Name__________________ Last Name__________________ Birth Date _____/_____/_____
1st Gender_________ Grade_________ School___________________________________________
Allergies / Special Needs ___________________________________________________________
First Name__________________ Last Name__________________ Birth Date _____/_____/_____
2nd Gender_________ Grade_________ School___________________________________________
Allergies / Special Needs ___________________________________________________________
First Name__________________ Last Name__________________ Birth Date _____/_____/_____
3rd Gender_________ Grade_________ School___________________________________________
Allergies / Special Needs ___________________________________________________________
*By registering my child for KidLife Children’s Ministry, I authorize that my child’s image may be photographed, filmed
and be used in video, print, and web publications.
*By giving my email address, I understand that I will be added to Life Church’s mailing list. Life Church will not give
your personal information to any third parties.

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