Child Information

First Name: *

Last Name: *

Age: *

School: *

Grade: *

Email Address: *

Additional Information (i.e. Allergies, special needs, etc.):

Parent Information

Parent Name: *

Emergency Contact(if other than Parent):

Contact Number: *

By submitting my e-signiture below I signify that the above names child has permission to attend and participate in the Valparaiso University MLK MY Buddy and Me project on Saturday, January 14th.

Parent e-Signature: *