Mid-Week PK Club Registration

Register for the current year PK Club program

Family Name

Child #1

Child #2

Child #3

Child #4

Parents/Guardians:

and

Address:

Phone Numbers: use ###-###-#### format

Home:

Dad Work: Dad Cell:

Mom Work : Mom Cell:

Email Address (for reminders):

Emergency Contact:

Medical Insurance: Carrier: Policy # Group #

Physican:

Food Allergies?

Please list any condition(s) that might effect your child(ren)/youth and list medications:

Medical Release:

By clicking below, I authorize First Presbyterian Church of Farmington to seek medical assistance for my child(ren) while participating in the LOGOS program. I also will assume responsibility for any costs incurred for my child(ren)'s medical treatment.

I Agree Date:

Permission to be Photographed and/or Videotaped

I give my permission for my son/daughter, to be photographed and/or videotaped for publicity materials to be used by

First Presbyterian Church or for inclusion on the church’s website. Names will not be used.

I Agree No, I prefer my child(ren)'s image not be used on the website. Date:

Tuition:
Tuition is $120/year per child/youth, payable in full in October or in two equal payments in October and January.

Please make checks payable to First Presbyterian Church and write “LOGOS” in the memo field. Financial assistance is available - please ask.