Ada Bible Church: Discovery Village Application

Discovery Village

Passport Creation

Location

Which campus will you be attending?

Cascade Campus North Campus Kentwood Campus

Personal Information

Child's Name

Male Female

Parents' names (or responsible person)

(relationship if not parent)

Home Phone

Medical concerns, allergies, conditions, etc.

Birth Date:

Grade for 2010-11

Pre-schoolers are placed by birth date, not age.

Permanent Name Tags

Would you like a permanent name tag? (Card must be filled in completely, and name tags may be discarded if a child is absent for 12 consecutive weeks)

Yes No

Child's mailing address City

State

Zip

Email address -- used for sending Family Ministries information only Other adults authorized to pick up my child

Service Preference

Saturday 5:30 Sunday 9:15 Sunday 11:00

School child attends Name of one or two friends or a leader your child knows
(We can't guarantee placement but we will try our best to acommodate everyone)

Privacy

We periodically use children's ministry pictures for our web site and other ABC publications. If you do not want us to use any picture with your child in it, please check here.

Special Needs

Does your child have any medial or behavioral concerns, allergies, special needs, etc. ?

Severity

Mild Moderate Severe Life Threatening

Diagnosis