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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<html>
<head>
<title>Redeemer: Reply Form</title>
<link rel="stylesheet" href="RLC.css" type="text/css">
<SCRIPT LANGUAGE="JavaScript" type="text/javascript" src="RLC.js"> </script>
</head>
<body class="bakimage">
<!--<h1>Education</h1>-->
<img src="Buttons/Education_t.JPG" width="233" height="40" alt="Education" border="0">
<hr>
<p>Please complete a separate form for each of your children.</p>
<form method="post" action="mailto:[email protected]">
<table>
<!--<tr colspan="4">-->
<!-- <td>Please complete a separate form for each of your children.</td>-->
<!--</tr> -->
<tr>
<td align="right">Child's First Name:</td>
<td><input type="text" name="ChildFirstName" size="40" maxlength="40"></td>
</tr>
<tr>
<td align="right">Child's Last Name:</td>
<td><input type="text" name="ChildLastName" size="40" maxlength="40"></td>
</tr>
<tr>
<td align="right">Parent/Guardian's First Name:</td>
<td><input type="text" name="ParentFirstName" size="40" maxlength="40"></td>
</tr>
<tr>
<td align="right">Parent/Guardian's Last Name:</td>
<td><input type="text" name="ParentLastName" size="40" maxlength="40"></td>
</tr>
<tr>
<td align="right">Address (line 1):</td>
<td><input type="text" name="Address1" size="80" maxlength="80"></td>
</tr>
<tr>
<td align="right">Address (line 2, if required):</td>
<td><input type="text" name="Address2" size="80" maxlength="80"></td>
</tr>
<tr>
<td align="right">City, State and Postal code:</td>
<td><input type="text" name="City" size="40" maxlength="40">,
<input type="text" name="State" size="2" maxlength="2">
<input type="text" name="PostalCode" size="10" maxlength="10"></td>
</tr>
<tr>
<td align="right">Home phone:</td>
<td><input type="text" name="HomePhoneAC" size="3" maxlength="3">.
<input type="text" name="HomePhoneXG" size="3" maxlength="3">.
<input type="text" name="HomePhoneNum" size="4" maxlength="4"></td>
</tr>
<tr>
<td align="right">Cell phone:</td>
<td><input type="text" name="CellPhoneAC" size="3" maxlength="3">.
<input type="text" name="CellPhoneXG" size="3" maxlength="3">.
<input type="text" name="CellPhoneNum" size="4" maxlength="4"></td>
</tr>
<tr>
<td align="right">Email Address:</td>
<td><input type="text" name="Email" size="80" maxlength="80"></td>
</tr>
<tr>
<td align="right">Child's Age:</td>
<td><input type="text" name="ChildAge" size="2" maxlength="2"></td>
</tr>
<tr>
<td align="right">Child's Date of Birth (MM/DD/CCYY) - </td>
<td>Month: <input type="text" name="ChildDOBmm" size="2" maxlength="2">
Day: <input type="text" name="ChildDOBdd" size="2" maxlength="2">
Year: <input type="text" name="ChildDOBccyy" size="4" maxlength="4"></td>
</tr>
<tr>
<td align="right">Child's Gender (M/F):</td>
<td><input type="radio" value="M" name="ChildGender" size="1" maxlength="1">Male
<input type="radio" value="F" name="ChildGender" size="1" maxlength="1">Female</td>
</tr>
<tr>
<td align="right">Child's Last School grade completed if applicable):</td>
<td><input type="text" name="ChildLastGrade" size="2" maxlength="2"></td>
</tr>
<tr>
<td align="right">Child's Siblings:</td>
<td><textarea rows="4" columns="80" name="ChildSiblings"></textarea></td>
</tr>
<tr>
<td align="right">Home faith community (church) - if any:</td>
<td><input type="text" name="HomeFaith" size="80" maxlength="80"></td>
</tr>
<tr>
<td colspan="2">In case of emergency, contact: (when parent/guardian listed above cannot be reached)</td>
</tr>
<tr>
<td align="right">Contact Name:</td>
<td><input type="text" name="EmergencyContactName" size="80" maxlength="80"></td>
</tr>
<tr>
<td align="right">Contact Phone:</td>
<td><input type="text" name="EmergencyPhoneAC" size="3" maxlength="3">.
<input type="text" name="EmergencyPhoneXG" size="3" maxlength="3">.
<input type="text" name="EmergencyPhoneNum" size="4" maxlength="4"></td>
</tr>
<tr>
<td align="right">Contact's relationship to child:</td>
<td><input type="text" name="EmergencyContactRelationship" size="80" maxlength="80"></td>
</tr>
<tr>
<td align="right">Please list any allergies/medical needs to which our staff should be alerted:</td>
<td><textarea rows="4" columns="80" name="ChildMedicalNeeds"></textarea></td>
</tr>
<tr>
<td align="right">Person responsible for picking up this child at the end of VBS each day:</td>
<td><input type="text" name="PickupPerson" size="80" maxlength="80"></td>
</tr>
<tr>
<td align="right">Phone:</td>
<td><input type="text" name="PickupPhone" size="12" maxlength="12"></td>
</tr>
<tr>
<td valign="top" align="right">Please check below any areas in which you would be able to assist:</td>
<td><input type="checkbox" value="Kitchen" name="AssistArea">Kitchen<br>
<input type="checkbox" value="Art" name="AssistArea">Art<br>
<input type="checkbox" value="Music" name="AssistArea">Music<br>
<input type="checkbox" value="Storytelling" name="AssistArea">Storytelling<br>
<input type="checkbox" value="Teaching" name="AssistArea">Teaching<br>
<input type="checkbox" value="Recreation" name="AssistArea">Recreation</td>
</tr>
<tr>
<td valign="top" align="right">Please check the evening(s) that you would be able to assist:</td>
<td><input type="checkbox" value="Monday" name="AssistDay">Monday<br>
<input type="checkbox" value="Tuesday" name="AssistDay">Tuesday<br>
<input type="checkbox" value="Wednesday" name="AssistDay">Wednesday<br>
<input type="checkbox" value="Thursday" name="AssistDay">Thursday<br>
<input type="checkbox" value="Friday" name="AssistDay">Friday</td>
</tr>
<tr>
<td align="right"><input type="submit" value="Submit"></td>
<td><input type="reset" value="Reset/Clear" name="reset"></td>
</tr>
</table>
</form>
<hr>
<h4>GO BACK TO <a href="RLC_Main.html" target="main">WELCOME PAGE</a></h4>
<script type="text/javascript">
AddCopyright();
</script>
</body>
</html>