Registration Form

 

Date
Child Information
Child's Name
First Name
Middle
Last Name
Age
Grade
Birth date
Name of school child attends
Who has custody?
Child custody arrangements
Allergies?
Please describe allergies
Has child attended DCFK before?
If yes, where and when
Church child attends/city
Are there special accommodations that we need to be aware of regarding your child?
If yes, please explain
Registering Parent Information
Parents Name
First Name
Middle
Last Name
Address
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Home Phone
Work Phone
Cell Phone
Email
Current Marital Status
Date separated/divorced/remarried
Persons living in your home other than siblings
If a court ordered restraining order has been issued on behalf of any of your children, a copy is required for our DC4K files (confidentially filed).
Other Parent Information
Name
Address
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Home Phone
Work Phone
Cell Phone
Email
Persons living in this parent's home other than siblings:
Emergency Contact Information
In case of emergency, contact one of the following people (other than parent):
Name
First Name
Middle
Last Name
Relationship
Home Phone
Work Phone
Cell Phone
Email
Name
Home Phone
Work Phone
Cell Phone
Email
Pick-up Authorization. If I am unable to pick up my child, the following person is authorized to do so. A photo identification will be required.
Name
Relationship
Current address
Address
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Home Phone
Work Phone
Cell Phone
Consent and Release Form. I understand that DC4K is not a counseling service or therapy program but a Biblically based, Christ-centered program to help children of divorce heal in a group setting. DC4K is designed to bring children of divorce into the loving arms of a church family and to feel God's love surrounding them.
Registering Parents Name
Date
$15 Registration Fee