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Parent/Guardian Information

Name *

First

Last

Phone *

Email

Photography Notes Concerns

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Child

Name *

GenderMaleFemale

Date of Birth

MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Grade Last Competed

T-Shirt SizeYouth SmallYouth MediumYouth Large/Adult SmallAdult MediumAdult LargeAdult Extra LargeAdult 2XAdult 3XOther (indicate in notes)

Medical Concerns

Notes

Photography *— Select Choice —Yes, you have permission to photograph my child, and post the fun they are having.No, please do not photograph the fun my child is having.

We love to post the fun we are having on the church’s social media. May we include your child(ren)?

Does your child regularly attend church?

• Yes, at FBC Harahan
• Yes, at a different church
• No, not really

What church?

Submit