Name
Home Address
Phone
Email
Emergency Contact Name
Emergency Contact Number
Child 1 Name/Age
Does this child have any medical needs or allergies?	Yes No
If so, please explain here
Child 2 Name/Age
Does this child have any medical needs or allergies?	Yes No
If so, please explain here
Child 3 Name/Age
Does this child have any medical needs or allergies?	Yes No
If you have more than 3 children, please list the remaining information here
As a spouse of a deployed military personnel, please check all that would be most helpful to you.	Financial (bills etc.) Counseling/Support Childcare Lawn Care / Home Maintenance Spiritual Guidance / Prayer
Please take a moment to identify any other needs that our ministry could meet for you.