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Good Book Club Registration

Gender *
Address
Address
Dad's work/cell phone
Dad's work/cell phone
Mom's work/cell phone
Mom's work/cell phone
Does your child attend church?
Child's Grade *
Grade
Child's Date of birth *
Child's Date of birth
Emergency Contact #1 *
Emergency Contact #1
Emergency Contact #1 Phone *
Emergency Contact #1 Phone
Emergency Contact #2 *
Emergency Contact #2
Emergency Contact #2 Phone *
Emergency Contact #2 Phone
Pick Up Authorization #1 *
Pick Up Authorization #1
This person is authorized to pick up my child if I am not able.
Phone *
Phone
Pick Up Authorization #2
Pick Up Authorization #2
This person is authorized to pick up my child if I am not able.
Phone
Phone
This person is authorized to pick up my child if I am not able.
Phone
Phone
We will encourage mentors to send notes of encouragement to children
Picture Waiver