Parent's Name:_______________________________________________________

Parent's Address:____________________________________________________

_____________________________________________________________________

Home Phone Number:___________________________________________________

Email Address:_______________________________________________________

Names and dates of birth of all children 0-4 yrs who will be attending PPH
(Please include infant siblings)

Name:________________________ DOB:______________ Allergies: ______________

Name:________________________ DOB:______________ Allergies: ______________

Name:________________________ DOB:______________ Allergies: ______________

Cost is $20.00 per child per session. This fee is nonrefundable).Siblings
15 months and younger are welcome to attend at no cost.

____ number of children x $20 = $________

How did you hear about our program?

Newspaper_____ Friend_____ Brochure_____ Other (specify)_____________

Are you currently a member of a church? Yes No

Name of church:______________________________________________________

We periodically use pictures from Power Hour on our website, in brochures, and in
publicity releases to the local paper. Please sign here to give St. Matthew's
permission to use photographs of you and your child.

Signature:_________________________________ Date:_____________________

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