Wednesday Night Registration
Note: If the email "SEND" fails, you can cut and paste this FORM into your email personal email setup.
For questions, please call the EUM office at 618-263-6561
Wednesday Night Child Registration
Children's Information:
Last Name First name M/F D-O-B Age Grade Entering
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3.
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Special Information:
Do any of your children have any allergies, medical conditions, or concerns
that we should be aware of?
Children's Favorite Foods. .:
Parent Information:
Father's Name. . . . :
Cell:
Mother's Name. . . .:
Cell:
Guardian's Name. . :
Cell:
Children's Address. :
State:
Zip:
Same As:. . . : Both:
Father's:
Mother's:
Other:
Home Phone. . . . . :
Email Address. . . :
Additional Emergency Contact Information:
Name. :
Number:
Name. :
Number: