Stockade (3rd-6th Grade) Registration 2018-2019
 
Stockade (3rd-6th Grade) Registration 2018-2019
First and Last Name (Child 1)  * 
Date of Birth (MM/DD/YYYY) (Child 1)  * 
Age (Child 1)  * 
Grade (3rd-6th grades) (Child 1)  * 
School Attending (Child 1)  * 
Hobbies/Sports (Child 1)
First and Last Name (Child 2)
Date of Birth (MM/DD/YYYY) (Child 2)
Age (Child 2)
Grade (3rd-6th grades) (Child 2)
School Attending (Child 2)
Hobbies/Sports (Child 2)
Street Address  * 
City  * 
Zip Code  * 
Parent/Guardian (1) Name  * 
Parent/Guardian (1) Cell Number  * 
Parent/Guardian (1) Home Number  * 
Important Announcements will be sent primarily to Email accounts to save on paper waste.
Your Email Address  * 
Parent/Guardian (2) Name
Parent/Guardian (2) Cell Number
Parent/Guardian (2) Home Number
2nd Email
Doctor’s Name  * 
Doctor’s Phone  * 
Special needs or food ALLERGIES  * 
Name of Health Insurance  * 
Insurance Membership Number
Emergency numbers to call in the event you cannot be reached DURING CLUB HOURS
Emergency Contact First and Last Name  * 
Emergency Contact Relation  * 
Emergency Contact Phone Number  * 
RELEASE AND WAIVER: In the event of illness or injury incurred by my child, whose name is shown at the top of this form, I authorize the leaders/workers of the Stockade Club of Forcey Bible Church to consent to emergency medical treatment and to execute any documents in my name, place, and stead to accomplish said purpose provided, however, the administration of the program shall first make all reasonable efforts to inform me of such illness or injury.
Signature  * 
Date (MM/DD/YYYY)  * 
Where are you most interested in helping? For example, games, crafts or Bible lessons? Dads or other significant adult men in the Stockader’s life who would like to be a part of Stockade should contact Vince Stepanik at vincent.stepanik@gmail.com.
Enter amount paying - Registration fee is $60 for each Stockader  * 
Stockade Shirts and Activity Books are required for each Stockader.
Stockade Activity Books are $14.00 each. Enter total amount paid for each Activity Book.  * 
Stockade shirt size (Youth sizes: 8, 10, 12, 14, 16, 18, Adult sizes: S, M, L, XL) (enter size for Child 1)
Stockade shirt size (Youth sizes: 8, 10, 12, 14, 16, 18, Adult sizes: S, M, L, XL) (enter size for Child 2)
Stockade shirts are $25 each (enter amount paying)
Ranger’s shirt sizes M, L, XL, 2X, 3X (enter size)
Ranger's shirts are $30 (enter amount paying)
Please enter any amount that you would like to contribute to the Club (assists with club needs, trips, equipment, etc.)
Enter Total Amount to pay  * $ 
Personal Notes/Family Needs: Please let us know if your Stockader has any unique needs or challenges that you think we would need to know about; and let us know if there are any is facing your family that Stockade can support you with.
We’re GLAD you’ve chosen to be a part of Stockade 555!
Total $
 
 
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