Alpha - FriendSpeak

Name *

First

Last

Email *

Mobile Phone *

Address: Street *

City *

State *

Postal Code (Zipcode) *

Please let us know who you are: *

Which group will you attend? *

English
Spanish/Alpha en Español
Chinese/ lead by Luke and Sarah Chong
Hindi

How did you hear about the Alpha course at Grace Fellowship? *

What Church do you attend (if any). If you don't attend church please write "none". *

Is there any additional information you feel would be helpful for us when placing you in a small group?

Do you give us permission to share your contact information with your group leader? *

Yes
No

Media Disclosure. I understand that church activities may be taped and/or photographed for church use. Entry into any church property or attendance at a church function constitutes consent to be photographed and images to be used for church purposes on the website, printed materials, and videos aired in public venues. *

I understand

Will you need childcare? Childcare is available for children 8 weeks to 10 years of age only. *

Yes
No

Number of Children

1
2
3
4

Child 1- List the first and last name of child number 1* *

example: Bobby Jones,

Child 1- List the date of birth for child number 1* *

example: 11/15/2009

Child 1- List any allergies for child number 1. Please type NA if not applicable* *

example: peanut allergy

Child 2- List the first and last name of child number 2 *

example: Bobby Jones,

Child 2- List the date of birth for child number 2 *

example: 11/15/2009

Child 2- List any allergies for child number 2 *

example: peanut allergy

Child 3- List the first and last name of child number 3 *

example: Bobby Jones,

Child 3- List the date of birth for child number 3 *

example: 11/15/2009

Child 3- List any allergies for child number 3 *

example: peanut allergy

Child 4- List the first and last name of child number 4 *

example: Bobby Jones,

Child 4- List the date of birth for child number 4 *

example: 11/15/2009

Child 4- List any allergies for child number 4 *

example: peanut allergy

If you have more than four children requiring childcare please list the information for those additional children below. Include the following information for each additional child: first and last name, date of birth, and any allergies or special needs.

Do any of your children require special needs assistance?*

Are you bringing an Epi pen for your child?* *

Name of children with Epi pen. *

Does your child have a history of seizures?* *

Media Disclosure: In order to receive childcare services at Grace Fellowship, please read and consent to the following: “I understand that church activities may be taped and/or photographed for church use. Entry into any church property or attendance at a church function constitutes consent to be photographed and images to be used for church purposes on the website, printed materials, and videos aired in public venues.” *

I agree

Childcare Policy Agreement: In order to receive childcare services at Grace Fellowship, please read and consent to the following: Childcare Policies* By reserving a space for childcare, I agree that my children will be utilizing childcare for every session of the group. If my child does not need childcare for a session, I agree to inform the Childcare Coordinator at least one week prior to the session. If my child is unable to attend due to a family member being sick, I will contact the Childcare Coordinator as soon as possible. If my child is absent 3 times without giving the Childcare Coordinator one week prior notice, the Childcare Coordinator and Ministry Contact will decide if the church can continue to provide childcare for my child. *

Yes, I agree to the above Childcare Agreement
No, I would like to discuss these policies further

Name of children needing special assistance. *