• • Child's Name *
    
    First
    
    Last
• • Child is: *
    Male
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• • Address *
    
    Street Address
    
    Other Address (optional)
    
    City
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    Region (optional)
    ...United StatesCanadaJapanUnited KingdomAustraliaGermanyFranceSwitzerlandItalyNetherlandsAlbaniaAlgeriaAmerican SamoaAndorraAnguillaAntarticaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBotswanaBouvet IslandBrazilBritish Indian Ocean Terr.Brunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslColombiaComorosCongoCook IslCosta RicaCote D'IvoireCroatiaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEstoniaEthiopiaFaeroe IslandsFalkland Isl. (Malvinas)FijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern Terr.GabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey C.I.GuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslHondurasHong KongHungaryIcelandIndiaIndonesiaIrelandIsle of ManIsraelItalyJamaicaJapanJersey C.I.JordanKazakhstanKenyaKiribatiKorea Republic ofKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLiechtensteinLithuaniaLuxemborgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslMartiniqueMauritaniaMauritiusMexicoMicronesiaMoldova Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherland AntillesNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslNorthern Mariana IslNorwayOmanPakistanPalauPanamaPanama Canal ZonePapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts & NevisSaint LuciaSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSt. Vincent & GrenadinesSurinameSvalbard & Jan Mayen IslSwazilandSwedenSwitzerlandTaiwanTajikistanTanzania United RepublicThailandTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslTuvaluU.A.E.U.S.Minor Outlying IslUgandaUkraineUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican City StateVenezuelaViet NamVirgin Isl (British)Virgin Isl (U.S.)Wallis & Futuna IslandsWestern SaharaYemen Republic ofZaireZambiaZimbabwe
    Country
• • Parent/Guardian Name *
    
    First
    
    Last
• • Parent/Guardian Primary Phone *
    
    
    
    
    
    
• • Parent/Guardian Secondary Phone *
    
    
    
    
    
    
• • Parent/Guardian email *
    
    
• • Parent/Guardian Other Contact Number
    
    
    
    
    
    
• • Grade just completed by child? *
    ...Young Preschool (Volunteers Only)Pre-KK1st2nd3rd4th5th
    
• • T shirt size *
    Child/Youth Medium
    Child/ Youth Large
    Adult Small
    Adult Medium
    Adult Large
    Adult Xlarge
    
• • Emergency Contact Name (other than parent/guardian) *
    
    First
    
    Last
• • Emergency Contact Phone Number *
    
    
    
    
    
    
• • 1. Name of person (other than parent or guardian)authorized to pick up child
    
    First
    
    Last
• • 1. Phone number of person listed as authorized person 1.
    
    
    
    
    
    
• • 2. Name of person (other than parent or guardian) authorized to pick up child
    
    First
    
    Last
• • 2. Phone number of person listed as authorized person 2.
    
    
    
    
    
    
• • 3. Name of person (other than parent or guardian) authorized to pick up child
    
    First
    
    Last
• • 3. Phone number of person listed as authorized person 2.
    
    
    
    
    
    
• • Please include any info to help us better serve your child this week (allergies, ADHD, shy, etc)
    
    
• • I hereby authorize St. Stephen Lutheran Church to obtain medical attention for my child in case of emergency. I agree to cover all expenses incurred and will not hold St. Stephen or any of its representatives liable. *
    I agree
    
• • I release St. Stephen Lutheran Church and its representatives to use my child's image in video, photograph and electronic reproduction for any event, publication, and/or website of St. Stephen Lutheran Church without compensation. *
    I agree
    

• • Registration is contingent upon full payment. Payment is due at time of registration, either by online payment or by check at St. Stephen office.

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