Sign up for Pioneer Club
September 2007 - May 2008;
6:15PM - 7:45PM
Age 3 through the 5th grade
Every other Tuesday starting September 18, 2007
Contact Information
Parent/Guardian Information:
Full Name:
Address
City and State
Zip Code
Home Phone
Emergency Contact Name
Emergency Contact Phone
(e.g. Cell Phone)
Home Church
Email Address:
Child's Information: (All young children must diaper independent)
First Name
Last Name
Child's Name Attending
Date of Birth
Age
Last Grade Attended
Age
3
4
5
6
7
8
9
10
11
12
Grade?
Not in school yet (no Diapers)
K
1
2
3
4
5
2nd Child's Name
First Name
Last Name
Date of Birth
Age
Last Grade Attended
Age
3
4
5
6
7
8
9
10
11
12
Grade?
Not in school yet
K
1
2
3
4
5
3rd Child's Name
First Name
Last Name
Date of Birth
Age
Last Grade Attended
Age
3
4
5
6
7
8
9
10
11
12
Grade?
Not in school yet
K
1
2
3
4
5
Enter any Special Needs (including allergies or medical conditions) in the space provided below: