Clovis Unified

Child’s School (please chose from the drop down list)*
BorisBud RankCedarwoodCenturyClovis ElementaryColeDry Creek ElementaryMickey CoxFugmanGarfieldGettysburgJeffersonRed Bank Elementary SchoolLibertyLincolnMaple CreekMiramonteMountain ViewOrazePinedaleReaganSierra VistaTarpeyTemperance-KutnerWeldonWoods

“Confirm Club room with School office!”

Child’s Name*

Birthdate*

is allowed to attend the Good News Club every week after school until the Club concludes – see list for dismissal time. (There will be no clubs on school holidays.) I understand it is my responsibility to pick up my child immediately after the club, and failure to do so will jeopardize my child’s continued participation.

Parent/Guardian Electronic Signature*

Typing your name here is your legal signature.

Check here to show how your child will get home on club day.*

My child will be picked up from the Good News Club room.My child will walk home or take the school bus.My child goes to the school’s extended day/after-school program.

Child’s Information

Child’s Grade & Homeroom Teacher*

Child’s Address*

StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinois IndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontana NebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvania Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

List any security/custody issues with this child?

List any special needs (ADD, Asperger’s, Dyslexia, etc.)

Parent/Guardian’s Email*

Home Phone*

Dad’s Work/Cell*

Mom’s Work/Cell*

Is either parent in the military?*
NoYes

Emergency Contact Person(s)

Full Name & Phone Number*

Child’s Allergies(peanuts, chocolate, etc)*

Church/Pastor Name( Optional)

These people (include phone numbers) are allowed to pick up my child if I’m not able:

OPTIONAL Photography and Video Release

Child Evangelism Fellowship may, from time to time, document the activities of the ministry with photos or videos.
I hereby assign and grant to Child Evangelism Fellowship Inc., its subsidiaries and successors, and assign the unqualified right to the ownership, use and proceeds of all photographs or video of me or my minor child, without reservation or limitation, including use of photographs or video of me or my minor child for, but not limited to, advertising, educational and promotional purposes.

YesNo

Typing your name here is your legal signature.

IMPORTANT: If you miss a required field on this form and are unable to submit your application, please refresh this page and try again by filling out all the required fields as well as the checkbox below.