Little Lambs - Registration & Medical Release 2024

Child Information

Name

Date of Birth

CURRENT age range or preschool grade

Turning age 3 by January 1, 2024 Currently in P3 (i.e., entering K4 this fall, 2024) I'm not sure

Address

Primary Contact Information

Primary Contact's first and last name

This address will receive a confirmation email

Enter the best contact number below.

Mobile

FPLC's Little Lamb's Medical Release

Medical Release: In the event that I cannot be reached in an emergency, I give the program’s coordinator permission to secure and administer treatment, including hospitalization, for the child whose name is listed below:

Child's first and last name

Family physician

Physician's phone

Emergency Contact: In an emergency, if the primary contact is unavailable, who would you like us to contact? (Enter their first and last name.)

What is their relationship to your family?

Their mobile number

Child’s medication or environmental allergies

Dietary restrictions

Physical activity restrictions

I give the program’s coordinator permission to secure and administer treatment, including hospitalization, for the child listed above.

Primary Contact's signature (Enter primary contact's first and last name as signature.)

Today's Date

Program Payment $75.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Little Lambs 2024

DATE
June 17 - 21

TIME
9:15–11:45am

COST PER CHILD
$75

(*Scholarships available. Contact the Church Office.)

QUESTIONS?
Contact Julie Schlifske at julie@foxpointchurch.org

Little Lambs - Registration & Medical Release 2024

Description

Please Fix the Following