Pre-Registration for Children’s Ministry

Date Attending*
MM slash DD slash YYYY
Hour expected*
- 9:15am
- 11:00am
Child's Name*
First Last
Child's Age Group*
- Birth-Pre K (Waumba Land)
- K-5th Grade (UpStreet)
Grade*
If other, please make note*
Age*
Birth Date*
About Your Child:
Allergies?
Parent's Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Cell Phone*
Home Phone
Email*
Marital status*
- Married
- Single
Spouse's Name*
First Last
Media Release
I grant to Journey, its representatives, and employees the right to take photographs, video, and/or electronic images of any member of my family in the Upstreet environment. I authorize Journey to copyright, use, and publish the photographs, video, and/or electronic images in print and/or electronically - with or without our names - for any lawful purposes to highlight and promote UpStreet environments. My digital signature below indicates that I have read and understand the above statement of release:
Do you agree to the Media Release statement above?*
- Yes
- No
Signature*
Sign using your mouse or touchscreen device
Today's Date*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Media Release