Kids ROCK/Club 56 Registration

    Your Name (required)

    Your Email (required)

    Child's Name

    Grade

    Address

    City

    State

    Zip

    D.O.B.

    Email

    Allergies/Medical Conditions: (food & environment)

    Special Needs:

    T-Shirt Size

    Comments:

    Parent/Guardian Contact Information

    Parent/Guardian Name(s)

    Address (if different than child)

    Home Phone

    Work Phone

    Cell Phone

    Parent/Guardian Signature

    Date

    Parents of Club 56 Kids please see John Shirron to sign a special Permission Slip.
    How Can I Help?

    DirectorGather SuppliesMusicGamesCraftsClub 56 Circle Leader (Riverguide)Set Up/Clean Up