Backyard Bible Club Registration

* Indicates required field

Child's Name *

First

Last

Please list other children you are registering (including Age & Grade). *

Backyard Bible Club Location *

Age *

Last grade completed *

June 13th-16th | 10:00-11:30am

This year there are three locations for Backyard Bible Club!
East Fayetteville 4214 W Anthem Dr. West Fayetteville 1073 E Bonnie Ln. Prairie Grove 12967 Green Earth Rd.

Please check our Facebook & Instagram for any weather updates.

Parent/Guardian Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Mailing Address (if different) *

Line 1

Line 2

City

State

Zip Code

Country

Phone Numbers and Email

Home Phone *

Work Phone *

Mobile Phone *

Email *

Medical Information or other information we need to know.
(Please include any food or other allergies)

Medical Information *

Emergency Contacts (other than listed above)

Emergency Contact 1 - Name *

Emergency Contact 1 - Phone Number *

Emergency Contact 2 - Name *

Emergency Contact 2 - Phone Number *

Dismissal Information
Who may pick up your child at the end of each Backyard Kids Club?

Name of the person(s) who may pick up your child. *

Other Information

Do you attend church? If so, where? *

May we have permission to photograph your child? *

Yes No

May we have permission to use your child's photograph for the purpose of promotion, including social media? *

Yes No

Submit

Backyard Bible Club Registration

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