FCC Children/Youth Registration 2024/2025

Child/Youth's Name

Child/Youth's Gender

Child/Youth's Preferred Name/Nickname

Child/Youth's Age

Child/Youth's Birthdate

Child/Youth's Grade in Fall 2024

Child/Youth's Address

Child/Youth's Email (if applicable)

Parent/Guardian 1 First Name

Parent/Guardian 1 Last Name

Parent/Guardian 1 Phone Number

Parent/Guardian 1 Email

Parent/Guardian 1 Address

Parent/Guardian 2 First Name (if applicable)

Parent/Guardian 2 Last Name

Parent/Guardian 2 Phone Number

Parent/Guardian 2 Email

Parent/Guardian 2 Address

Any allergy/dietary concerns for Child/Youth?

Does Child/Youth have a cell phone?

Yes No

Child/Youth's Phone Number (if applicable)

Any other concerns that the staff should be made aware of? (Ex. Any behavioral/social diagnoses, an IEP/503 Plan, etc.)

Photo/Video Release: I give First Congregational Church permission to use photos/videos of my child. Use may include, but is not limited to, website, social media, and emails.

Yes No

Medical Emergency Release: In the event that I cannot be reached, I authorize all necessary medical treatment as prescribed by the attending physician and/or emergency response personnel, and I release First Congregational Church from liability.

I agree to the stated terms.

Description

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FCC Children/Youth Registration 2024/2025

Description

Please Fix the Following