REGISTRATION: Boomerang Express

____________________________ ______________________ __________________

Last Name First Name Middle Initial

ADDRESS___________________________________________________ City________________ Zip_______

BIRTHDATE_______________________ HOME PHONE__________________ CELL_____________________

GRADE_________ PARENT’S NAME(S)_________________________________________________________

E-MAIL ADDRESS__________________________________________________________________________

WHO MAY PICK UP YOUR CHILD AT THE END OF EACH SESSION?____________________________________

ALLERGIES OR LEARNING NEEDS______________________________________________________________

EMERGENCY CONTACT #________________ CONTACT PERSON____________________________________

INSURANCE CARRIER_______________________________________ INSURANCE #____________________

In case of accident or medical emergency, we will do our best to contact you in a timely manner. Your child
will be cared for in the most appropriate method possible. Your permission is needed to receive medical care
for your child. Please sign below agreeing to this. Church at the Crossing will not be responsible for any
medical costs accrued.
PARENT’S SIGNATURE_______________________________________________ DATE___________________

HOME CHURCH____________________________________________________________________________
Please check all boxes below that you desire.

I would like printed information about Church at the Crossing.

I would like to speak with someone about Church at the Crossing..

I have church home.

I attend occasionally.

Please put me on your e-mailing list so I can receive updates as to special events for families and children at
CATC.

T-SHIRT ORDER
T-shirts are color fast, 100% cotton. Cost is $10 each payable upon registration.
Enter the quantity of shirts in the blank before each size..

___ Children’s XS (2-4) ___ Adults Small (34-36) ___ Adults 2XL (50-52)
___ Children’s Small (6-8) ___ Adults Medium (38-40) ___ Adults 3XL (54-56)
___ Children’s Medium (10-12) ___ Adults Large (42-44)
___ Children’s Large (14-16) ___ Adults X-Large (46-48)

Number of t-shirts _____ X $10.00 = __________________ Paid by cash check (Check number_______)
(circle which one)
C:\Users\Matthew\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\AC4K7AWP\REGISTRATION (2).doc
OFFICE USE only – registration

____________________________ ______________________ __________________

Last Name First Name Middle Initial

Group Assignment______________________________ Group Leader ________________________________

Ordered and received t-shirt
Yes

Attendance
Monday Tuesday Wednesday Thursday Friday

Did this child come with a friend? If so, what is the child’s name?_____________________________________

C:\Users\Matthew\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\AC4K7AWP\REGISTRATION (2).doc