Kindertreff Registration - Coral Gables Congregational United Church of Christ

Number of children to be registered:*

Child 1 Information

Child 1 Name*

First Last

Child 1 Birth Date*

Child 1 Allergies/Dietary Restrictions/Health Concerns*

Please list.

Child 2 Information

Child 2 Name*

First Last

Child 2 Birth Date*

Child 2 Allergies/Dietary Restrictions/Health Concerns*

Please list.

Child 3 Information

Child 3 Name*

First Last

Child 3 Birth Date*

Child 3 Allergies/Dietary Restrictions/Health Concerns*

Please list.

Child 4 Information

Child 4 Name*

First Last

Child 4 Birth Date*

Child 4 Allergies/Dietary Restrictions/Health Concerns*

Please list.

Child 5 Information

Child 5 Name*

First Last

Child 5 Birth Date*

Child 5 Allergies/Dietary Restrictions/Health Concerns*

Please list.

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

Emergency Contact Information

Name*

First Last

Relationship to child*

Home Phone

Cell Phone*

Medical Information

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.

Health Agreement

I agree to the following:*

It will be each parent’s responsibility to ensure their child is well and free of fever before attending Kindertreff events. If your child is not feeling well or has a fever of 100 degrees F or higher, Deutsche Kirchengemeinde Miami requests that they remain home until their fever has ended. Further, should anyone in your family have a positive COVID-19 test before or after attending a Kindertreff event, please email germanministry@gablesucc.org. Your communication will be private and your confidentiality will be protected.

Other Information

Answering these questions is voluntary.

Religion/Church Member of:

Is your child/Are any of your children baptized?

Yes
No

If yes and you are registering more than one child, please list the names of those who are baptized.

Are you interested in “Religionsunterricht” (Sunday school) in German Language?

Yes
No

Signature

Parent's/Guardian's Digital Signature*

Date*