To

Pastor Tom

Subject

2010/2011 Kids Quest & Breakout Registration

Parent Name

Your Email *

Your Phone *

Your Address *

Emergency Contact *

Doctors Name and Phone *

Allergies ???

Childs Name

---> Birthdate

---> Grade

Pre-K born before 2005Kindergarten1st2nd 3rd 4th5th

2nd Child

---> Birthdate2

---> Grade2

Pre-K born before 2005Kindergarten1st2nd 3rd 4th5th

3rd Child

---> Birthdate3

---> Grade3

Pre-K born before 2005Kindergarten1st2nd 3rd 4th5th

4th Child

---> Birthdate4

---> Grade4

Pre-K born before 2005Kindergarten1st2nd 3rd 4th5th

Note to Pastor Tom:

Cost

Please Select One One Child $60Two Children $120Three Children $180 Four Children $240Request Scholarship (include note above)

Don't let money keep your family away from Kid's Quest / Breakout. Limited amount of scholarship moneys are available.. include a note to Pastor Tom above to apply for a scholarship.

On the next page you can pay through Paypal (You do not need a PayPal account and can use your Credit Card)

* Email Address and/or Phone are required fields