Disciple City Registration Form

Disciple City Registration

Questions? Contact Jen Pearson (712)-359-7706 for additional information.

Registration Form

* Indicates required field

Name *

First

Last

Age and Grade *

Parents / Guardian *

Address, City, State/Zip *

Home / Cell Phone *

Email *

Emergency Contact Name and Phone *

Medical Treatment Authorization It is my understanding that the church will attempt to notify me in case of a medical emergency involving my child. If the church cannot reach me, then I authorize the church to hire a doctor or health-care professional, and I give my permission to the doctor or other health-care professional to provide the medical services he or she may deem necessary. I will pay for any medical expenses so incurred. I will notify the church if I feel there are any health considerations that would prevent my child’s participation in any of the activities listed above. I also give my permission for the church’s children’s and/or youth leaders to restrict my child from participation in any activity for the sake of their health or safety. *

I agree I do not agree

Allergies | Medical Concerns *

List name(s) of guardian for pick up after Disciple City *

Submit