Child's Name

First Name

Last Name

Parent/Guardian Name

Home Phone

Work Phone

Cell Phone

Email Address

Address

Are You a Resident of Walton Planned Community?

Yes

Child's Age

Last Grade Completed in School

Medical Information

Please describe any medical or other information we need to know including any known food allergies.

Emergency Contact 1

Name/Relationship to Child/Phone Number

Emergency Contact 2

Name/Relationship to Child/Phone Number

Dismissal Information

Who may pick up your child at the end of the day?

Other Information

Do you or your child attend church? If so, where?

May we have permission to photograph your child?

(We have photographers getting pictures and videos of all our church events.)

Yes

May we have permission to use your photographs that include your child for our promotional materials?

Yes