Pioneer Club Registration

Pioneer Club

2009-2010 Registration Form

First through Fifth Grades (one per Family please)

Meeting at Trinity Family Center ~ 614 Badlands Road ~ Hudson, WI 54016 ~ 381-1414

Child 1

Name 
Age:   Birthdate:   Grade:  

Child 2

Name 
Age:  Birthdate:   Grade:  

Child 3

Name 
Age:   Birthdate:   Grade:  

Parents/Guardians Names:  

Address:  

City/State/Zip:  

Home Phone:  

Mother’s Cell:  

Father’s Cell:  

Email:  

Doctor’s Name:  

Doctor’s Phone:  

Allergies:

Special instructions or information about child:

Person(s) authorized to pick up my child:  

Emergency Contact Name:  

Relationship:  

Phone:  

Signature of Parent or Guardian: 

Print Name (required):  

Date:  

Are you interested in a fun and easy mentoring opportunity?
 Yes, sign me up! I’m interested, tell me more! Maybe, a few times through the year

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