Freedom Explorers Youth Summer Program

28202 Franklin Road, Southfield, MI | 248-761-3999

First name

Last name

Email address

Phone

Home address (street, city, state, zip)

(a separate registration form must be completed for each child)

Child's full name

Date of birth

Month

Day

Year

Grade entering this fall

T-shirt size

Allergies, medications, or medical conditions we should know about (write “none” if not applicable)

Name

Phone Number

Names of adults authorized for pickup

Parents are required to drop off and pick up children on time each day. FiC Ministry will provide transportation to field trips only.

I am this child's parent or legal guardian, and I consent to their participation in Freedom Explorers Youth summer

program activities, transportation to field trips, and to emergency medical treatment if needed, and I cannot be reached.

I consent to my child being photographed or filmed for program materials (optional).

Parent / guardian signature

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Date

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