REAL Registration Form

Please fill out this form and click submit.

Child's Name 1

*

Parent/Guardian Name

*

Gender

*

Please select one option.

Male Female

Age

*

Grade

*

Please select one option.

Nursery PreK K 1st 2nd 3rd 4th 5th

Date of Birth

*

Child's Name 2

Gender

Please select one option.

Male Female

Age

Grade

Date of Birth

Child's Name 3

Gender

Please select one option.

Male Female

Age

Grade

Date of Birth

Child's Name 4

Gender

Please select one option.

Male Female

Age

Grade

Date of Birth

Address

*

Phone

*

Emergency Contact

*

Phone

*

Do you attend Pinewood?

*

Please select one option.

Yes No

If no, where do you attend?

Where will you be during REAL?

*

Phone

*

Would you be available as needed to substitute in a class?

*

Medical Release Form

Doctor's Name

*

Phone

*

Are any of your children allergic to any foods?

*

Please select one option.

Yes No

If yes, list child’s name and food allergy:

In case of a medical emergency*, I hereby give my permission to the physician selected by a member of the Children’s Ministry staff to secure proper treatment and/or hospitalization for my child(ren).

By checkin this box, you agree to the terms above.

*

Please select all that apply.

Name

*

Date

*

*We will make every effort to reach the parent/legal guardian listed, or the emergency contact given on your registration form. Is there anything else we need to know?

Payment

REAL is only $10 per child for the first two children, and $5 per additional child. Your payment covers the entire year of REAL! ***The fee applies only to children in PreK through 5th Grade!*** Please calculate your amount due and type it in the box below. If you prefer to pay by cash or check, please bring your payment with you on the first day of REAL.

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

Please fill out this form and click submit.

Please Fix the Following

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