Birthday *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (or guardian's phone) *

(###)

###

####

Parent or Guardian Name *

First Name

Last Name

Emergency Phone *

(###)

###

####

Parent or Guardian Phone *

(###)

###

####

Program *

WHIZ-KIDZ (elementary) Mondays 3:30 pm to 5:30 pm

WHIZ-KIDZ (elementary) Thursdays 3:30 pm to 5:30 pm

DISCOVERY/JOURNEY (middle school/high school) Mondays 5:30 to 7:30 pm

DISCOVERY/JOURNEY (middle school/high schoo) Tuesdays 3:30pm to 5:30 pm

Activities Permission *

By checking this box and providing my information below, I give my child permission to participate in activities with adult supervision as listed above, and therefore, remove all liability and responsibility from Freedom for Youth Ministries.

Yes, I agree

No, I don't agree

Do you authorize Freedom for Youth to produce photographs, videos, and presentations that include images of your child.

Yes

No