K-5th Grade
Pioneer Boys
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 Boys)
Parental Authorization
I give permission for my child to participate in the Pioneer Boys 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