First name (or name that child goes by):  * Last name:  * Parent/Guardian Name:  * Address:  * City:  * State:  * Zip code:  * Home Phone or Main Contact Phone:  * Cell Phone: Email: Date of Birth:  * Last Grade Completed:  * Gender:  * Known Allergies or information we should know:  * Emergency Contact Name #1:  * Emergency Contact Phone #1:  * Emergency Contact Name #2: Emergency Contact Phone #2: Authorized Pickup Name #1:  * Authorized Pickup Phone #1:  * Authorized Pickup Name #2: Authorized Pickup Phone #2: Are you a member of Beulah? What church do you attend? May we have permission to photograph your child?  * May we have permission to use your child's photograph in church publications?  * Comments: Do not enter anything in this field: