2020-2021 Children and Youth Ministry Registration Form - Coral Gables Congregational United Church of Christ

Child/Youth Information

Child's/Youth's Name*

First Last

Birth Date*

MM

DD

YYYY

Age*

As of September 1, 2020

Gender*

Church Member of*

Gables UCC
No Church

Baptized*

Yes
No

Youth's Cell Phone

Youth's Email

Grade*

During the 2020-2021 school year.

School*

During the 2020-2021 school year.

Special Interest and Activities*

Allergies/Dietary Restrictions

Please list.

Siblings Attending Sunday School*

Yes
No

Names and Ages

Parent/Guardian Contact Information

Parent's/Guardian's Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone*

Email*

Second Parent's/Guardian's Name (if applicable)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone

Email

Additional information that would assist us in ministering to your child/youth:*

Does your child/youth have any disability of which we should be aware in order to best serve your child/youth? ALL INFO REMAINS CONFIDENTIAL.*

Emergency Contact Information

Name*

First Last

Relationship to child*

Home Phone

Cell Phone*

Name

First Last

Relationship to child

Home Phone

Cell Phone

Name of Health Insurance Company*

Policy Number*

Medical Consent*

I authorize medical treatment for my child in case of accident or illness if the parent/guardian cannot be located and an emergency situation arises.

Media Release

Media Release*

I give permission to use my child's name, photograph, and/or performance recordings (including audio and/or video forms) in brochure, web, and other promotional materials.

I would like to volunteer for Sunday School (choose which area you would like to help).

Parent's/Guardian's Digital Signature*

Date*

MM

DD

YYYY