Heritage Lutheran Church


 

Heritage Lutheran Church
308 N. Washington Street
Valparaiso, IN 46383

Be Amazed!!

August 6—10, 2007

9—11 AM
 

For information, call 464-2810 or email heritagelc@verizon.net

Registration Form

(one per child please)

Child’s Name_______________________________________________

Grade Completed__________________      Age__________________

Parent’s Names_____________________________________________

Address_____________________________________________________

Home phone_____________________  Cell Phone__________________

Emergency Contact Person_____________________________________

Relationship to child____________________________________________

Emergency Contact phone______________________________________

Food Allergies              Yes           No

          List Allergies

Medical Concerns          Yes          No

          Explain

Church Membership at___________________________________________