THE LIFE CHURCH – 1 Old Westbury, Old Westbury, NY 11568 Tel 516 333 3355 www.thelifeny.org FORMULARIO DE INSCRIPCIÓN REGISTRATION FORM Nombre (Name) __________________________________________________________ Age ____________ Dirección (Address) _________________________________________________________________________ Ciudad (City) ________________________________ Estado (State) _________________ ZIP _____________ Teléfonos (Phone) ______________________________________ Celular (Cell) _____________________ CE (Email) _____________________________________________ Grado escolar completado (Grade completed) ___________________________________________________ Contactos en emergencia (Emergency contacts) __________________________________________________ _________________________________________________________________________________________ Madre (Mother) ___________________________________________________________________________ Padre (Father) _____________________________________________________________________________ Otros (Other) _____________________________________________________________________________ _________________________________________________________________________________________ Alergias/Problemas médicos (Allergies/Medical Problems) ________________________________________ _________________________________________________________________________________________ Iglesia (Home Church) ______________________________________________________________________ Nombre de amigo con quien su hijo(a) quisiera estar: ____________________________________________ (Name special friend your child would like to be with): ___________________________________________ Firma Madre/Padre o Apoderado ____________________________________________ Por favor mande por correo el Formulario de Inscripción completado a: Please mail the completed Registration Form to: Att: Paulina Janssen, Ministerio Hispánico THE LIFE Church, 1 Old Westbury Rd., Old Westbury, NY 11568