Clubhouse Registration

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Please fill out the form below to register for Children's Clubhouse. If more than two children will be attending, please fill out another form.

Child Information
If more than two children will be attending please fill out another form.
Child 1 Name
Birthdate
mm/dd/yyyy
Age
Child 2 Name
Birthdate
mm/dd/yyyy
Age
Child 3 Name
Birthdate
mm/dd/yyyy
Age
Child 4 Name
Birthdate
mm/dd/yyyy
Age
Need to Register Additional Children?
Add Child 3
Add Child 4
Do any of the above children have food allergies or medical concerns (e.g., asthma)?
Yes
No
If Yes, please list child name and allergy or medical concerns in space below:
Parent/Guardian Information
Parent/Legal Guardian Name
Mobile Phone
Phone Number

Address

Email
Emergency Contact Information
Emergency Contact Name
Relationship to Child
Mobile phone for emergency contact
Phone Number
List persons authorized to pick up your child
Name
Phone
Phone Number
Name
Phone
Phone Number
Name
Phone
Phone Number
Need to Add an Additional Person?
Add Person 3
By signing below, I authorize my child to attend and participate in Community Nazarene Church’s Children’s Clubhouse and associated activities.
Parent/Guardian Signature
Date
Month - Day - Year

ADDRESS

58 Cumberbach Street
Wyandanch, NY 11798

CONTACTS

(631) 920-6844 contact @ communitynazchurch.org

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Child Information