(5th Grade) Block Party Registration Fall 2022/ Spring 2023

Student Information

Name

Address

Age

School

Transportation to Block Party

Bus Pickup from School Guardian Drop-off

Medical Concerns/Allergies

I, the parent or legal guardian of this child, grant FUMC Marble Falls my permission to use photographs, videos, and audio for any legal use, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content.

Yes No

Parent/Guardian Information

Parent/Guardian Name

Parent/GuardianEmail

This address will receive a confirmation email

Parent/GuardianPhone

Parent/GuardianAddress

Additional Parent/Guardian Information

Additional Guardian Name

Additional GuardianEmail

Additional GuardianPhone

Additional GuardianAddress

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship to Child

Primary Care Physician

Pickup Permissions

These people have permission to pick up my child.

Pickup Name 1

Pickup Phone 1

Pickup Name 2

Pickup Phone 2

Pickup Name 3

Pickup Phone 3

Description

Wednesdays, 3:30 - 5:30 PM

Please fill out this form to register your 5th Grade student for Block Party 2022-23 and click submit.

(5th Grade) Block Party Registration Fall 2022/ Spring 2023

Description

Please Fix the Following