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Fields with (*) are required.
Child's First Name(*)
Please let us know your name.

Child's Last Name(*)
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Birth Date(*)
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Grade Completed(*)
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Sex(*)

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Parent/Guardian(*)
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Your Email(*)
Please let us know your email address.

Home Phone(*)
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Work Phone
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Cell Phone
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Home Church
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Address(*)
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City(*)
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State(*)
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Zip code(*)
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Preferred Number to Contact(*)

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Emergency Contact(*)
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Relationship to Child(*)
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Emergency Contact Phone(*)
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Food Allergies(*)

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List Allergies
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Medical Concerns
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Persons authorized to pick up the child other than the parent/guardian(*)
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When you have completed filling out the form, enter the Security code and click the Submit button. The information will be sent to West Houston Bible Church to register your child and will not be used for any other purpose.
Security code(*)
Security code
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