Leesburg Seventh-day Adventist Church

Soaring Eagles Valentine's Day Fundraiser Registration

1. Child First Name

2. Child Last Name

3. Child Age

4. Child Grade

5. Parent Name 1

6. Parent Name 2

Email

Phone Number

Child Allergies/Dietary Restrictions

Additional Child Information/Comments

Emergency Contact 1

Phone

Emergency Contact 2

Phone

Who may pickup your child at the end of the fundraiser?

Name

Relationship

Name

Relationship