Kids Basketball League

PAY ONLINE

Click Below to Pay

REGISTER
[[[["field17","contains","yes"]],[["show_fields","field18"]],"and"]]
1 Step 1

Child's Information

Child's First Name
Child's Last Name
Age (on 1/6/18)

DOB:

Address

Number & StreetNumber & Street
CityCity
Sex

Parent/Guardian Information

Mother's Full Namefull name
Mom's Primary #primary #
Mom's Secondary #secondary #
Father's Full Namefull name
Dad's Primary #mobile #
Dad's Secondary #secondary #
Do You Attend Church Somewhere?
If so, where?

Emergency Contacts (other than parents)

Please list in order to call. We need at least one.
1) full namefull name
1) phonephone number(s)
1) Allowed to Pick Up Child?
Relationship
2) full name
2) phonephone number(s)
2) Allowed to Pick Up Child?
Relationship

Medical Information

Doctor Name
Doctor Phone
Insurance Company
Insurance Phone
Insurance Group #
Hospital Preference
Allergiesif any (separate by comma)
0 /
Medical Conditionsif any (separate by comma)
0 /

WE NEED VOLUNTEERS - Will you help?

Volunteers Needed
After completing this form, please sign your name electronically and submit the form.
You will need to pay one of two ways BY NOVEMBER 11, 2017:
1) Pay online with a debit/credit card -- the info is on this page & will be emailed to you
2) Pay in the church office during business hours - phone: 662.895.5481

Photo Release

My child may be photographed/video recorded and used by FBCOB for promotional purposes.

Electronic Signature

My child:

child's name

is currently up-to-date on all required immunizations.  First Church Olive Branch (FBCOB) has my permission to seek medical attention for this same child as determined by the staff.  FBCOB also has my permission to transport this same child to the hospital designated.  Parents will be contacted ASAP.

Full Name
Today's Date
Previous
Next