REGISTRATION - Westminster Presbyterian Church

Parent Information

Parent Name *

First

Last

Parent Cell Phone *

Parent Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Church Home (if any)

Student Information

Select Program *

Student Name *

First

Last

Date of Birth *//

Grade in School *

School Name

Does your child have allergies? *

Yes
No

List allergies: *

Does your child have a medical condition? *

Yes
No

Describe medical condition(s):

Additional children?

Yes
No

Select Program *

2nd Student's Name *

First

Last

Date of Birth *//

Grade in School *

School Name

Does your child have allergies? *

Yes
No

List allergies: *

Does your child have a medical condition? *

Yes
No

Describe medical condition(s): *

Additional children?

Yes
No

Select Program *

3rd Student's Name *

First

Last

Date of Birth *//

Grade in School *

School Name

Does your child have allergies? *

Yes
No

List allergies: *

Does your child have a medical condition? *

Yes
No

Describe medical condition(s): *

Additional Children?

Yes
No

Select Program *

4th Student's Name *

First

Last

Date of Birth *//

Grade in School *

School Name

Does your child have allergies? *

Yes
No

List allergies: *

Does your child have a medical condition? *

Yes
No

Describe medical condition(s): *

Physician Information

Family Physician *

Physician's Phone Number *

Special concerns?

Photo Waiver

Westminster may use media of my child(ren) for future promotional materials.

Multiple Choice

Yes
No

Payment

Please note the following fees: One (1) student is $80 (for Fall & Spring); Two (2) students in same family is $150; Three or more (3+) students in the same family is $175. Payment should be submitted to the church office.

I agree to pay: *

One student ($80)
Two students ($150)
Three or more ($175)

(Please choose one based on the number of kids you are registering.)

Captcha *

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Missionaries: Inviting, Growing, Serving.
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Please fill out the form below to register.

Parent Information

Student Information

Physician Information

Photo Waiver

Payment