Club

* Select your club location:

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Location:
Room:
Time:

Sponsoring Church:
Club Captain:
Email:

Household

Address

* Country:  -- Cuba Dominican Republic El Salvador Ghana Guatemala Mexico Nicaragua Trinidad and Tobago United States País:  -- Cuba El Salvador Estados Unidos Ghana Guatemala México Nicaragua República Dominicana Trinidad y Tobago

* Address line 1:

Address line 2:

* City:

* State:

*ZIP:

Parent/Guardian information

* Your full name:

* Relation (e.g. Mother):

* Your email:

* Your Phone Number:
+1 Cell Home

Student

Student Information

First Name:

Last Name:

Gender: --- M F

Grade:

Birthday: 
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 Cumpleaños: 
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 enero feb mar abr mayo jun jul agosto sept oct nov dic 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002

Health and Wellbeing

Please select any concerns we should be aware of:

Allergies
Physical Limitations
Other Concerns

If you checked any boxes, please explain how we can best support your child and family:

After Club

After club, we should:
--- Dismiss your child to walk home unsupervised. Dismiss your child to another program. Release your child to you or one of your authorized pickups.

Which program?

Authorized Pickups

Authorized pickup 1:

Authorized pickup 2:

By checking the box below and submitting this form I am registering my child for the Crossroads Club program. I understand that this is a faith-based program, that it is my discretion to enroll my child in this program, and I have read and agree to the terms and conditions above regarding my child’s participation in the program. I also understand that my child will be expected to conform to the Crossroads code of conduct and if s/he does not, I will be notified and they may be removed from the CKC program.

I agree to the above statement.