Asbury Kids Registration Form 2024-2025

Child Information

Child's Name:

Child's DOB:

Child's Address:

Child's Current Grade:

Child Food Allergies:

Parent Information

Parent/Guardian Name:

Parent/Guardian Phone Number:

Parent/Guardian Email:

This address will receive a confirmation email

Emergency Contact & Pickup Information

Emergency Contact Name (different than above, please):

Emergency Contact Phone:

Secondary Pickup Person:

Secondary Pickup Person Phone:

Payment Information

Semester Payment:

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

August 14-December 11, 2024 | January 8-May 14, 2025

Please fill out the form below to register your child for Asbury Kids, our Wednesday night program, for 2024-2025. Asbury Kids starts at 5:30 pm and ends at 7 pm.

Please fill out one form per child.

Asbury Kids Registration Form 2024-2025

Description

Please Fix the Following