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Name: ____________________________________________
Age: ________ |
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Street Address : ___________________________________________________ |
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City: ______________________________
State: ________ Zip: __________ |
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Home Telephone: ( ______ ) _________________________________________ |
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Cell Telephone: ( ______ ) ___________________________________________ |
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Date of Birth: _____ / _____ / _____ (mm/dd/yyyy) |
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Last school grade completed: _________________________________________ |
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In case of emergency, contact: ________________________________________ |
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Mother: __________________________________________________________
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Father: __________________________________________________________
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Other: ___________________________________________________________
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Allergies or other medical conditions: ___________________________________ |
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Home Church: _____________________________________________________ |
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Lab Crew number (for church use only): _________________________________ |
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Return by Mail: |
St. Paul Lutheran Church - 30600
Thousand Oaks Blvd. - Agoura Hills, CA 91301 |
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Return by Fax: |
(818) 889 - 1649 |
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For more information, contact the
church office at (818) 889 - 1620. |
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