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Child's Name * First Last
Sibling Name * First Last
Sibling Name * First Last
Parent Name * First Last
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email *
Emergency Contact *
Phone Number * ### - ### - ####
Payment Method *

Each child is $15 and there is a family cap of $25. All payments should be made in person at The Well prior to July 26th. Please make checks out to The Well and put "Create" in the Memo line. All payments can be made in person at The Well, placed in the Box of Jubilee before or after worship, or mailed to:

The Well
190 Sierra Court Suite C2
Palmdale, CA 93550

If you have any questions or are in need of a scholarship please Contact Pastor Todd at 661.492.0110
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