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First name *
Age of Child *
Last name
Grade in Fall 2021 *
Address *
Parent's Name *
Cell Number of Parent *
Does Parent Speak English?
Yes
No
How did you hear about the program? *
Food Allergies of Child *
Any Medical Conditions that cause physical limitations: *

Please number classes with a 1 – 1st choice, 2- 2nd choice, 3 – 3rd choice

Soccer *
Blacktop Sports (Basketball, Street Hockey, Frisbee, Foursquare, Dodgeball) *
Sewing / Cooking *
Camping Skills *
Email Address *
Questions/Comments *
Accept Terms *

I give my child permission to participate in Summer Expressions on Sunday Nights at Grace Community Church 126 Walnut Ave, Placentia from July 11-August 15 from 5:45pm – 8pm. I agree to fill out a liability form in person.

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