Kids Rock Registration firstbaptist@midconetwork.com(605) 224-20302310 E. Capitol Ave.Pierre, SD 57501 Child's Name * First Name Last Name Gender * Male Female Date of Birth * MM DD YYYY Last school grade completed * Nursery Pre-K Kindergarten 1st 2nd 3rd 4th 5th 6th grade or higher Parent's Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Mailing Address (if different) Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email Home Church Do you give consent for First Baptist Church to use pictures of child on the church website/Facebook for informational or promotional purposes? * Grant consent DO NOT grant consent Allergies, medical conditions, or special needs Emergency Contact Name * First Name Last Name Emergency Contact Phone Number * (###) ### #### Emergency Contact Relationship to Child * Thank you!
