Do not press the ENTER key until you have entered all the information in the fields below.

iBLAST KIDS CLUB (Pre-K through 5th Grade) and iGNITE MIDDLE SCHOOL PROGRAM (6th through 8th Grade) start back up on Tuesday, January 22nd, at Christ Reformed Church.

Child's Full Name:

Child's Age:

Birth Date:


Current Grade Level:

School My Child Attends:

Parent or Guardian's Name:

Home Address, City, State, Zip:

Home Phone:

Work Phone:

Cell Phone:


Home Church:

Emergency Pick-Up #1 Name:

Emergency Pick-Up #1 Phone:

Emergency Pick-Up #2 Name:

Emergency Pick-Up #2 Phone:

Food Allergies/Medical Concerns (provide details)?

I give permission for my child's photo, audio or video recording to be used to promote Good News Clubs:

Enter CLUBS to ensure proper registration: