Henry Presbyterian Church

511 Wirt Street, P.O. Box 203,  Henry, Illinois, 309-364-3083

        Where the saving love of Jesus Christ is embraced in hospitality and ignited in service to the community

 

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Activitiy Registration Form

 

 

 

 

 

 

 
 

Activity Registration Form

 Activities Held at First Presbyterian Church of Henry

 

 

Child’s Name _______________________________________  Birthday _______________________

Entering Grade_____________________________________  Age _____________________________

Parent/ Guardians _____________________________________________________________________

Cell _______________________________      Home ___________________________

IN CASE OF EMERGENCY CONTACT:

Name _______________________________________________   Phone ____________________________

Preferred Doctor__________________________________   Phone ____________________________

Preferred Hospital _______________________________________

            PERSON (other than parents) AUTHORIZED TO PICK UP CHILD

Name _______________________________________________   Phone ____________________________

ALLERGIES or other health conditions which limit activity: ___________________________

______________________________________________________________________________________________

Print form, complete and  return registration to:

Henry Presbyterian Church

511 Wirt Street, Henry, Il 61537

 

 
 
 
 
 

First Presbyterian Church * 511 Wirt Street * Henry, IL
  309-364-3083