10:30 AM every Sunday beginning September 6th
Adirondack Community Church,
2583 Main Street, Lake Placid, NY 12946
Registration (Return to P.O. Box 511, Lake Placid; or Fax 523-3831)


Mother’s Name____________________I can help yes when?___

Fathers’s Name____________________I can help yes when?___

Address____________________________ City__________________

State_________ Zip__________email__________________________

Church _________________________ Member ? Yes _____ No____

Child’s Name _______________________________________________

Birthdate ______________ Age ____ School Grade Completed ____

Child’s Name _______________________________________________

Birthdate _______________ Age ____ School Grade Completed ____

Child’s Name _______________________________________________

Birthdate ______________ Age ____ School Grade Completed ____

I give my permission for my child/children to be photographed:

yes no

Signed_________________________________________________

Allergies?______________________________________________

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