Registration Form  

Pioneer Clubs begins Wednesday, October 3, 2007.  Complete the registration form below and click on submit to register.

 Full Name of First Club Member

 Birth Date   Boy    Girl

Choose age or grade3 years old4 years old5 years oldKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth Grade

 Full Name of Second Club Member

 Birth Date   Boy    Girl

Choose age or grade3 years old4 years old5 years oldKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth Grade

 Full Name of Third Club Member

 Birth Date   Boy    Girl

Choose age or grade3 years old4 years old5 years oldKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth Grade

 Full Name of Fourth Club Member

 Birth Date   Boy    Girl

Choose age or grade3 years old4 years old5 years oldKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth Grade

CONTACT INFORMATION

 Parents or Guardians Full Names

 Address

 Telephone

  Email Address

 Emergency Phone Contact Phone

 Emergency contact if parent can't be reached

 Relationship

 Telephone

  I release all images of my children produced by the St. John Mennonite staff  and their volunteers for communicative and promotional purposes including, but not limited to flyers, videos and the St. John Mennonite website.

MEDICAL ALERT INFORMATION

Please include information of any medical concerns such as allergies or special learning needs in the box below.

Suggested Club Dues are considered donations to St. John Mennonite Church to help offset the expense of supplies and handbooks.  Checks may be made out to the church and mailed to 15988 Rd. 4, Panora, Ohio, attention: Duane Weaver.

Choose Amount$15 - 1 Child$25 - 2 Children$35 - Per Family

Thank you for registering your children for Pioneer Clubs!