HOPE II Registration Form - Lynchburg Covenant Fellowship

Child's Last Name *

Child's First Name *

Child's Address *

Child's Address

Street Address

Apartment Building and Apartment Number

City

State/Province

Zip/Postal

Country

Child's Age *

Birth Date *

School (Currently Attending) *

Grade *

Please type out the grade level.

Parent / Legal Guardian Full Name *

Parent / Legal Guardian Home or Cell Phone # *

Relationship to Child *

Parent / Legal Guardian Full Address *

Parent / Legal Guardian Full Name

Parent / Legal Guardian Home or Cell Phone #

Relationship to Child

Parent / Legal Guardian Full Address

List of All Allergies (Food and Environmental) *

If No Allergies, Please type "NONE"

List of All Medications (It is important that we know this, however, we are unable to administer medications. *

If No Medications, Please type "NONE"

Emergency Contact Person *

Emergency Contact Phone # *

Relationship of Emergency Contact to Child *

Does this person have your permission to pick up your child in case of emergency? *

Yes

No

Is there any other information we should know about your child, or any special accommodations needed in order for your child to participate in our Hope II program? *

If no other information is needed, please type "NONE"

Signature of Parent or Legal Guardian *

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