K-5th Grade
Pioneer Girls

 Name of Child

 Address of Child  Age of Child

 Birthdate of Child  Phone Number

 School Attending  Current Grade

 Parent's Full Name

 Person to call in an emergency

 Relationship of emergency contact

 Church that child attends

 Who will be bringing child?

 Who will be picking up child?

 Have you paid the $10 registration fee? (checks made payable to Pioneer Girls)

Parental Authorization  

I give permission for my child to participate in the Pioneer Girls Club of the Carlisle Brethren in Christ Church and to participate in all activities offered on the church premises January – April.  
Activities may include indoor games (gym time), some outdoor games, crafts, bible lessons, workbook activities, singing, and snacks.


 Full name of person authorizing

 

 Any activities my child SHOULD NOT participate.


 Please list ANY special medical conditions.


 Child's Physician  Phone Number

 

 Insurance Carrier  Group Number

 

In the event that someone cannot be reached in an emergency (sickness or accident), I hereby consent to the Carlisle Brethren in Christ church providing care through the Carlisle Hospital and/or nearby hospital or private doctor for the above named child.

 

 Full name of person giving medical consent

 Date I completed this form