Sully First Reformed Church

Kidz Movie Nite/Route 45 Registration Form

Activity Sign up


Please complete the information below.  Registration end date is Thursday, November 2.  If you have questions, contact Julie Van Manen by phone at (641) 594-2935 ext. 5 or email ( for Route 45(4th & 5th grade) or Lynn Dunsbergen by phone at 641-891-4864 or for Kidz Movie Nite (K - 3rd grade).   For a printed version of the registration form, click here.

        * = Required Data Entry 


* Child 1 Name (Required)
* Child 1 Gender (Required)
Male   Female
* Child 1 Birthdate - MM/DD/YYYY (Required)
* Child 1 Age (Required)
* Child 1 Grade (Required)
* Child 1 School (Required)
Child 1 Allergies
Child 2 Name
Child 2 Gender
Male   Female
Child 2 Birthdate (MM/DD/YYYY)
Child 2 Age
Child 2 Grade
Child 2 School
Child 2 Allergies
Child 3 Name
Child 3 Gender
Male   Female
Child 3 Birthdate (MM/DD/YYYY)
Child 3 Age
Child 3 Grade
Child 3 School
Child 3 Allergies
* Parent's Name, Address, Phone #, and email address
Emergency contact Person(other than parent) Name, Address, Phone #, and Email address
Additional Persons Authorized to pick-up your child(ren). Provide name and phone #. (Children will need to be picked up by 8:30 p.m.)

I give my permission for the staff of Kidz Movie Nite and Route 45 to provide emergency medical treatment.

Name of parent (w/date) granting approval.

Kidz Movie Nite/Route 45 has my permission to photograph or videotape my child(ren).  These photos may be released for use on the church website or local media for promotional and informational purposes.

Name of parent (w/date) granting approval.
Other Comments or Information:
* Email Address: