One Child Per Form, Please

Pioneer Clubs

Registration Form

(One child per form, please)

Name ______Girl/Boy______Grade _____

School ______Birthdate ______Age ____

(Month/Day/Year)

Child’s Home Address ______

Street City Zip

Child’s Home Phone ______Child’s Cell ______

(if applicable)

Child’s Email ______

(if applicable)

Allergies, special needs, etc. ______

Church You Regularly Attend ______

Mother ______

Home Address ______

(if different from child) Street City Zip

Home ______Cell ______Work ______

(circle best number)

Email ______

Father ______

Home Address ______

(if different from child) Street City Zip

Home ______Cell ______Work ______

(circle best number)

Email ______

Emergency contact ______

Relationship to child ______

Home ______Cell ______Work ______

(circle best number)

Email ______

Continued on back

Parents are asked to volunteer during at least one monthly meeting. Please select one or more dates:

_____ September 14, 2014 _____ January 11, 2015

_____ October 12, 2014 _____ February 8, 2015

_____ November 9, 2014 _____ March 8, 2015

_____ December 14, 2014 (tentative) _____ April 12, 2015

Pioneer Clubs is an international organization that provides a Bible-based curriculum including lessons, crafts, activities, games, and more. Registration costs cover fees, dues, badges, awards, student handbooks and supplies.

Please make checks payable to: Pioneer Clubs at SOTH. Payments may be made over several months. Scholarships may be available by contacting Julie Cole at or 303-238-2482. Return completed forms to or to the Shepherd Office as soon as possible. Payments are due by September 12 unless other arrangements are made.

$ 5.00 Registration Fee

$ 25.00 Dues

$ 8.00 Handbook (all students)

$ 38.00 Total Due

In order to ensure the safety of all children attending Pioneer Clubs, I will accompany my child in to the church building at the beginning of the meeting and I will come inside the church to pick up my child at the end of the meeting.

______

Parent Signature and Date

I give permission for my child to have his/her photo taken and displayed (without name) for Pioneer Clubs presentations, SOTH events, or for use on the SOTH website on the internet.

______

Parent Signature and Date

I authorize the following people to pick my child up from Pioneer Clubs:

Name ______Relationship ______Phone ______

______

Parent Signature and Date