Child's First Name *

Child's Last Name *

Child's Age *

Allergies

Child's Date of Birth *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Email Address *

Phone Number *

Mailing Address *

Mailing City *

Mailing State *

Mailing Zip Code *

Do you give your consent for photography/video to be taken of your child during KidsLife at Life Church? *