eMerge Registration

Family's Last Name

Mother and/or	Father

Child's name	birth date	grade

Street Address
City	State Zip
Home phone	Cell/Alternate phone
Email
Emergency Contact	phone
Physician

Any medical concerns/medications we should know about?
Name of special friend(s) your child would like to be with

I give my permission to have my child's photograph taken for church related purposes.

All children will be encouraged to give a weekly offering as a way to share their blessings.