This page contains the following forms:

DC4K Child Information Form (printable PDF )
Includes Registration, Emergency Contact Information, and Pick-up Authorization

DC4K Children's Registration (online submission)

DC4K Child Information Form (online submission)
Includes Emergency Contact Information and Pick-up Authorization

All information goes directly to Children and Family Ministries and will be kept confidential.

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DC4K Children's Registration Online Form

Child's name Age Grade Birthdate

Child's name Age Grade Birthdate

Child's name Age Grade Birthdate

Street address Apartment/Unit

City State Zip Phone E-mail

Person the child lives with

How did you hear about DC4K?

DC4K registration fee: $15.00 for one child, $30 for 2 or more children. Maximum $30 total per family. Covers all 13 weeks and includes workbook, weekly cost crafts, and snacks.

Payment Method

Payment attached
I'll bring it next week
Please cover my registration from the scholarship fund. We do not want finances to keep your child from coming to our DC4K group. If you need help with the registration fee, all you have to do is check this line, and the registration will be paid from our scholarship fund.

Nursery care is available from 6:50 until 8:15 for children ages birth through 4 at no charge. This service is only offered if the parent is attending DivorceCare. If you plan to bring children to the nursery, please list their names and ages below:

Child's name Age

Child's name Age

Child's name Age

Registering parent's name (this will serve as your signature for now)

Today's date


   

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DC4K Children's Information Online Form

Child's name Age Grade Birthdate

Street address Apartment/Unit

City State Zip Phone

Name of school child attends School telephone

Name of child's school teacher

Who has custody? Mother  Father Joint Guardian Other

Describe child's family situation and living arrangement

Describe child's visitation arrangement

Has child attended DC4K before? No  Yes  If Yes, When? Where?

Church child attends Location of church (city)

Are there any special accomodations we need to be aware of regarding your child in order to provide the best program for your child? No  Yes  If YES, please explain:

Does your child have any allergies, especially food allergies? No  Yes  If YES, please explain:

Is there anything else our DC4K leaders should know about your child? No  Yes  If YES, please explain:

SIBLING INFORMATION

Please indicate if sibling relationship is by birth, half, step or adoption.

Name Relation Grade Age

Name Relation Grade Age

Name Relation Grade Age

Name Relation Grade Age

CHILD'S MOTHER INFORMATION

Mother's name

Street address Apartment/Unit

City State Zip Home Phone Work Phone

Cell Phone E-mail

Employer Occupation

Current marital status

Date separated Date divorced Date remarried

Persons living in mother's home other than siblings:

Name Age Relationship

Name Age Relationship

CHILD'S FATHER INFORMATION

Father's name

Street address Apartment/Unit

City State Zip Home Phone Work Phone

Cell Phone E-mail

Employer Occupation

Current marital status

Date separated Date divorced Date remarried

Persons living in father's home other than siblings:

Name Age Relationship

Name Age Relationship

GENERAL INFORMATION

How did you hear about DC4K?

Will you be attending the adult DivorceCare ministry program? Yes No

CONSENT AND RELEASE FORM

I understand that DC4K is not a counseling service or therapy program but a biblically based, Christ-centered program to help children of divorce heal in a group setting. DC4K is designed to bring children of divorce into the loving arms of a church family and to feel God's love surrounding them.

Registering parent's name (this will serve as your signature for now)

Today's date

EMERGENCY CONTACT INFORMATION

In case of emergency, contact the following person(s) (other than parent):

1. Contact name Relationship

Street address Apartment/Unit

City State Zip Home Phone Work Phone

Cell Phone

2. Contact name Relationship

Street address Apartment/Unit

City State Zip Home Phone Work Phone

Cell Phone

PICK-UP AUTHORIZATION

If I am unable to pick up my child, the following person(s) are authorized to do so. A photo identification will be required.

1. Pick-up name Relationship

Street address Apartment/Unit

City State Zip Home Phone Work Phone

Cell Phone

2. Pick-up name Relationship

Street address Apartment/Unit

City State Zip Home Phone Work Phone

Cell Phone

Registering parent's name (this will serve as your signature for now)

Today's date

   

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