After School Program Winter Registration
January 15 - May 21, 2013

* Required


Child(ren) Information 


Female
male














Yes - I understand I will be contacted by Heather Hjelmstad - Ministry of Inclusion Coordinator
No



Yes
No

Parent/Guardian Information 






Permission Section 

I agree
I disagree

I agree
I disagree
Registration is not complete without payment. When you click submit, you will be brought to the e-pay page. Cost is $90 per child for those using transportation from Rush Creek or Basswood and $80 per child for those providing their own transportation. Full and partial scholarships are available. Please contact Pastor Todd at todd@lordoflife.org