Clarence Center-Akron Mennonite Church
Wednesday Evening Program Registration
* Required Field
*
Parent/Guardian(s) Name(s):
*
Parent/Guardian e-mail:
*
Home Phone:
Cell Phone:
*
Home Address:
Child's Name:
Age:
 Medical/Learning/Allergy Concern:
Grade:
Yes:
Maybe:
No:
Will you be staying for our adult program?  
Will you be staying in our nursery with an
infant or toddler:
Yes:
Maybe:
No:
Will someone else be picking up your child(ren)?  If so, please designate here or send your child(ren) with
note on the night this may happen.
Name:
Phone:
Emergency Contact Information
In the event of an emergency, every effort will be made to contact you at the number(s)
given above, then your emergency contact listed below.  Emergency personnel will be
called a the discretion of program leadership in the event you are unreachable.
*
Name:
 *
 Home Phone:
*
Relationship:
Cell Phone: