Event Registration

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Great Escape Fall 2017 Registration on Wednesday, August 16, 2017 @ 9:00 AM

Please indicate below which Class your child will participate in based on your child's age as of August 1, 2017. *If a Class is not listed then it is full (you may email ttacket@southlandchristian.org to get on a waiting list).

Parents, you are the attendee to this ‘event’.

 Please enter YOUR information in the ‘Attendee’ fields above.

non-refundable deposit is required upon submission of this registration to hold your child's spot (choose deposit amount in the 'Price' dropdown at top of this page).

Parent Information

*Your Relationship to Child:
Other Parent or Guardian First Name:
Other Parent or Guardian Last Name:
Other Parent or Guardian Phone:
Other Parent or Guardian Email:
Other Parent Relationship to Child:

Child's Information

*Child First Name:
*Child Last Name:
Child Preferred Name:
*Date of Birth:

Health And Allergy Information

Please list any allergies, health conditions, or allergic reactions

Medical Care information

*Family Doctor Name:
*Doctor's Address
*Doctor's City
*Doctor's Phone
Dentist's Name
*Dentist's Address
*Dentist's City
*Dentist's Phone
Provide information for two emergency contacts other than the parents.:
*Emergency Contact 1 Full Name:
*Emergency Contact 1 Cell Phone:
*Emergency Contact 1 Address:
*Emergency Contact 1 Relationship to Child:
*Emergency Contact 2 Full Name:
*Emergency Contact 2 Address:
*Emergency Contact 2 Cell Phone:
*Emergency Contact 2 Relationship to Child:

Special Pickup Instructions

*Is there court order restricting visitation of your child by a person? If yes, please list their names and relationship.

Both parents are legally allowed to pickup the child unless a court order is specified above. However, if you would like to give permission for aunts, uncles, grandparents, baby sitters, etc. to pickup your child, please complete the authorized pickup form for each person.

Add an authorized pickup for my child.
By submitting this registration, you are affirming that all information is correct to the best of your knowledge, and you agree to promptly notify the Great Escape Director's office of any changes to this information.