KIDZBLAST 2023

CHILD INFORMATION

• * First Name:
• * Last Name:
• * Grade Completed: --Choose-- 3rd Grade 4th Grade 5th Grade
• *

  Gender:

  • Male
  • Female
• * Birthday M/D/Y
• *

  Food Allergies

  • Yes
  • No
• List Food Allergies:
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• *

  Medical Concerns

  • Yes
  • No
• Explain Medical Concerns: Or if you prefer to talk about them to someone please call the church office and ask for Monique. 215-723-3220
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• T-Shirt Size

  • Youth Small
  • Youth Medium
  • Youth Large

REGISTERING MORE THAN ONE CHILD?

You may add a maximum of 5

PARENTS/GUARDIANS: Family Information

• * First Name:
• * Last Name:
• * Relationship to child:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• Address 2:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:
• * Emergency Contacts ( First & last name & phone)-list up to 2:
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• * Primary Transportation Person: First & last name as well as contact Phone #

• * Alternate Transportation Person: First & Last name as well as contact Phone #: