B.L.A.S.T. 2021
July 12th - 16th | Please fill out this form and click submit.
Child's Name
*
Child's Age
*
Child's Gender
*
Birthday
*
Parents/Guardians
*
Phone
*
Email
*
This address will receive a confirmation email
Mailing Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Preferred Method of Contact
*
Emergency Contact Information
Emergency Contact
*
Emergency Contact Relationship to Child
*
Emergency Contact Phone
*
Allergies/Other Medical Concerns We Should Know About
*
Additional Information
Home Church
*
Grade for 2021-2022 School Year
*
What School Will Your Child Be Attending?
*
If anyone other than you will be picking up your child, please list their names:
*
From time to time we like to take pictures and videos to post on our website and social media pages. I hereby grant Roebuck Baptist Church permission to use photographs of the child indicated in this form for their webiste, social media pages, and other publications without further consideration.
*
Please select all that apply.
Yes, I grant permission
No, I decline to grant permission
Print/Sign Name
*
Date
*
Submit
Description
July 12th - 16th
Please fill out this form and click submit.
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