Register Your Child

**Please note any helpful information about your child as you register in the additional comments.

*Does your child have a prefered pronoun/name?

*Do they have a buddy that they would like to be placed in the same group?

*Do they need any type of additional support or medical services?

We can't wait to see you in June! Until then, if you have any questions, please contact Ashley Gerard at ashley@worthingtonumc.com

We found some errors when you submitted your information. Please see below and fill in the information needed.

Parent Personal Information

Parent First Name:

Parent Last Name:

Address 1:

Address 2:

City:

Country:

State:

Zip:

Email:

Re-Enter Email:

Home Phone Number: (xxx-xxx-xxxx)

Cell Phone Number: (xxx-xxx-xxxx)

Other Phone Number: (xxx-xxx-xxxx)

Emergency Contact

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Phone 1: (xxx-xxx-xxxx)

Emergency Phone 2: (xxx-xxx-xxxx)

Alternate Pickup First Name:

Alternate Pickup Last Name:

Alternate Pickup Phone: (xxx-xxx-xxxx)

Other Information

Home Church (If Applicable):

How many from your family will be eating dinner with us? (Open to all in your family, not just your child participating!):

Does your child (or you if you are dining with us!) have any allergies or dietary restrictions?:

Please be sure to note the info requested under "Register your child." You can leave the notes in the "other information" field on the next page. This is helpful information for us to better serve your child :) :