Shipwrecked

Registration Form

(One Per Child)

Child's name:


Child's gender:


Child's age:


Date of birth:


Last grade completed:


Name of parent(s):


Street address:


City/State/Zip code:


Home telephone:


Parent/caregiver's cell phone:


Email address:


Home church:



Alergies or other medical conditions:


In case of emergency, contact name:


Their phone number:


Their relationship to the child:


Permission to post photographs of child:

Pictures are used on our App, website and facebook page for NPAG kidszone events.