2023-2024 Developers (K/1st) Registration
Rock Prairie Church, 421 Ash Street, Tipton, IN 46072
(765) 675-4588
Wednesdays from 6:00-7:30 p.m.
Please fill out this form and click submit.
Student Name
*
Birthdate
*
Grade in School
*
Address
*
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Parent/Guardian Name
*
Cell Phone
*
Email
*
This address will receive a confirmation email
Emergency Contact (if different than parent/guardian)
Relationship
Emergency Contact Phone
Invited by
Church
Special Consideration(s)
Siblings also attending
I give my permission for the above student to participate in program activities and games, and I realize that even when carefully supervised there is a chance that he/she could get hurt.
*
Please select all that apply.
By checking this box I give my permission for the above statement.
I will not hold the church and/or its representatives liable for injury, and I give my permission for the above named child to be treated in case of an emergency.
*
Please select all that apply.
By checking this box I give my permission for the above statement.
Yearly Dues & Handbook
Pay Online ($32.99)
Pay in Person (0)
Financial Assistance (0)
Pay Online ($32.99)
Pay in Person (0)
Financial Assistance (0)
Amount
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Submit
Description
Rock Prairie Church, 421 Ash Street, Tipton, IN 46072
(765) 675-4588
Wednesdays from 6:00-7:30 p.m.
Please fill out this form and click submit.
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