S.M.A.K. Registration

Completed 1st Grade through 6th Grade

Child's Name *
Child's Name
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Emergency Contact Phone
Emergency Contact Phone
(Must be Signed)

Amount is due first day of program July 22, 2019 - This information to be filled out by staff/church office at time of payment.

Paid Check $ ______ Check#_______ Paid Cash_____ $40 per child/ $ 80 family maximum.

*A medical release form must be completed for each child.