Student's Last Name:  
Student's First Name:
Gender: M F
 Home Phone:  
Birth date:
Address:
City:
State:   Zip:
Email:
Church (if you do not attend NPC, do you attend another church?)
 

Parent Guardian Information:

Mother/Father/Guardian:
Telephone:  
Email:

In Case of Emergency
Contact Name:
Emergency Contact Number    

Does this child have any disabilities, present injuries, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?  Yes  No

If Yes, please explain:

If you wish to have your doctor contacted in case of emergency please list Doctors name and Phone number.

In the space provided, please list any other needs or information that would be helpful to understanding any special needs:

 You will be connected to the online payment option upon clicking submit.
 If you have more than one child to register, you may combine the payments but please revist this page and register the second child.