1st Child's Name *

First Name

Last Name

1st Child Date of birth *

We'd love to know when to celebrate your child's birthday!

MM

DD

YYYY

2nd Child's Name

Fill in this information ONLY if you are registering a 2nd child

First Name

Last Name

2nd Child Date of birth

We'd love to know when to celebrate your 2nd child's birthday!

MM

DD

YYYY

3rd Child's Name

Fill in this information ONLY if you are registering a 3rd child

First Name

Last Name

3rd Child Date of birth

We'd love to know when to celebrate your 3rd child's birthday!

MM

DD

YYYY

4th Child's Name

Fill in this information ONLY if you are registering a 4th child

First Name

Last Name

4th Child Date of birth

We'd love to know when to celebrate your 4th child's birthday!

MM

DD

YYYY

Parent/Guardian's name *

First Name

Last Name

Phone *

Country

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact 1 *

First Name

Last Name

Emergency Contact 1 Phone *

Country

(###)

###

####

Media release

West End Baptist Church does NOT have my permission to use my child’s photograph publicly for promotional material. NB: The images may be used in print publications, online publications, presentations, websites, and social media. There is no royalty, fee or other compensation that will become payable to families for any reason when using the images in promoted material.

Date of Registration *

MM

DD

YYYY