Pioneer Club Registration

Child 1 Name (required)

Age (required)

Birthdate (required)

Grade (required)

Child 2 Name

Age

Birthdate

Grade

Child 3 Name

Age

Birthdate

Grade

Parent/Guardian Name (required)

Address (required)

Home phone (required)

Mother's Cell Phone

Father's Cell Phone

Email (required)

Doctor's Name (required)

Doctor's Phone (required)

Allergies/Other Medical Conditions

Special Instructions or information about child

Persons authorized to pick up child (required)

Emergency Contact if parent or guardian cannot be reached (required)

Emergency Contact relationship (required)

Emergency Phone (required)

First Aid and Emergency Medical Treatment
Students who are registered online will need to fill out and sign this section of the form on their first day of attendance.

Registration fee: $40 per child payable at first session. Make checks to: Trinity Lutheran Church.

Are you interested in a fun and easy mentoring opportunity? Be a small group leader or help with this program!
 Yes, sign me up I'm interested. Tell me more! Maybe. A few times during the year

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