The Upper Room

							                                                     The Upper Room
                                                       Registration
Date: _____________

Name (First, Last): ________________________                                                         Date of Birth: ___________

School Attending: ________________________                                                           Grade: ________________

Home Address: ____________________________________________________

City, State, Zip: _____________________________________________________

Home Phone: ________________ Email Address: ________________________

Parent/Guardian Contact (Name): ______________________________________

Contact Phone #: _______________ E-mail: _____________________________

Health Issues or Concerns we should be aware of: _________________________


I agree to abide by all of The Upper Room’s guidelines. I understand that if I do
not abide by these guidelines, I may be responsible for restitution and/or possibly
be asked to leave The Upper Room.

Signature: _________________________________________________________

**How did you hear about The Upper Room? Friend / School Flyer / Community
Flyer / School Announcements / Newspaper / Website / Other ________________
-----------------------------------------------------------------------------------------------------------------------------------------------------------
This section to be completed by the parent or guardian:


 __________________________ (Child’s Name) has my permission to attend
The Upper Room. I understand that it is my responsibility to arrange for
transportation to and from The Upper Room, and that The Upper Room ends
promptly at 10:30 PM. I authorize the use of my child’s image for publicity
purposes of The Upper Room.

Parent/Guardian Signature: ___________________________________________


                                                                                                                                                Revision 4