SPLAT 2010

Experience the excitement as we discover who God is and how He loves us. We are thrilled to offer this 3-day experience for our UR Tots. We promise it will be a time filled with stories, games, songs, and messy adventures.

Accepted forms of payment are: MasterCard

Contact Information * required

First Name *

Last Name *

Contact Phone *

Mobile Phone

Email *

Street

City

State

Postal Code

Kid's Name *

Birthday *

Gender *

Parent 2 Name *

Parent 2 Address

Parent 2 Email Address

Parent 2 Home Phone

Parent 2 Cell

T-shirt Size *

Please list the name of one child your son or daughter would like to be grouped with.

We typically divide children up by age/grade so please keep that in mind. We will do our best to honor your request.

Please let us know of any allergies or other special concerns. *

(i.e. food allergies, asthma, potty training, etc.) we need to know about your son or daughter. If your child has none, then please type "none".

Please describe any current physical, mental or psychological conditions requiring medication, treatment, or special considerations. *

If your child has none, then please type "none".

Please mark this box if you do not give the Upper Room Community permission to use pictures or video of your son or daughter for promotional/communication purposes.

Please note: we will not list your child's name alongside his or her photo.

Do not give permission

Because of our growing community, we need parents and families to serve in some capacity.

Check here if we can contact you regarding service opportunities for the 2010 UR Kids Summer Experiences.

You may contact me.

Total

Quantity	1
Price Per Ticket	$ 35.00
Pay With
TOTAL	$ 35.00