Event Registration

Back to Event Detail

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 smhahn@southland.church to get on a waiting list).

Please fill out the information below to register your child for Great Escape.

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

Child Information

*Child First Name:
*Child Last Name:
Child Preferred Name:
*Child's Home Address
*Date of Birth:
Please list any allergies, health conditions, or development delays/ diagnosis/ therapy that you are aware of?

Parent Information

*Parent or Guardian 1 (First and Last Name):
*Parent or Guardian 1 Phone Number:
*Parent or Guardian 1 Email:
*Parent 1 Relationship to Child:
*Parent or Guardian 2 (First and Last Name):
*Parent or Guardian 2 Phone Number:
*Parent or Guardian 2 Email:
*Parent 2 Relationship to Child:
Do you have a church home? If so, where?
*Are your or your spouse on staff at Southland Christian Church?
If yes, what is your role?
Has your ever child been enrolled in another program? If so, where?

Medical Information

*Family Doctor Name:
*Doctor's Phone
*Dentist's Name
*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 Relationship to Child:
*Emergency Contact 2 Full Name:
*Emergency Contact 2 Cell Phone:
*Emergency Contact 2 Relationship to Child:

Special Pickup Instructions

*Are there any special circumstances regarding custody or court orders regarding this child?

If yes, please include details below. 

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.