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Trailblazers After School Program Registration Form 2018-2019
NBUMC Site
Trailblazers After School is a Christ-centered program which collaborates with other local agencies, churches and ministries.
*
Indicates required field
Child's Name
*
First
Last
Male or Female
*
Male
Female
Nickname
*
Birth Date
*
Father's Name
*
First
Last
Father's Mobile Phone
*
Father's Home Phone
*
Father's Email
*
Fathers Home Address
*
Line 1
Line 2
City
State
Zip Code
Country
Father's Employer
*
Father's Occupation
*
Father's Work Phone
*
Father's Work Address
*
Line 1
Line 2
City
State
Zip Code
Country
Mother's Name
*
First
Last
Mother's Mobile Phone
*
Mother's Home Phone
*
Mother's Email
*
Home Address
*
Same As Father
Different Address (fill in below)
Mother's Home Address
*
Line 1
Line 2
City
State
Zip Code
Country
Mother's Employer
*
Mother's Occupation
*
Mother's Work Phone
*
Mother's Work Address
*
Line 1
Line 2
City
State
Zip Code
Country
Parents Marital Status
*
Married
Divorced
Seperated
Single
Widow/Widower
Please list other household members, relationship to child, and the age of any siblings.
*
IN CASE OF AN EMERGENCY, WHO SHOULD BE CALLED IF PARENTS ARE UNAVAILABLE?
Contact Name
*
First
Last
Best Contact Number
*
Relationship to Child
*
Contact Address
*
Line 1
Line 2
City
State
Zip Code
Country
Health Information
Are immunizations up to date?
*
List of Allergies
*
Special Medical Conditions
*
Trail Blazers has several sites. This online application is for the site at the address listed below. You will receive more specific information from the Trail Blazer's Staff once your application has been received and processed.
Site:
New Brighton United Methodist
1033 Sixth Ave.
New Brighton, Pa 15066
Office Phone- 724-843-3774 Office Hours- M through F 9 a.m. to 1 p.m.
Submit
Home
Who We Are
Our Vision
This Church
The United Methodist Church
Our History
NBUMC Staff
When We Worship
Traditional
Contemporary
How We Serve
Outreach
Children + Youth
Adults
Get Involved
NBUMC Preschool
Events/News
Calendar
Connect
Contact Us
Find Us
Request Prayer
Donate Online
Church Directory
Forms
>
Room Request Form
Preschool Registration Form
Trailblazers Registration Form
Employment