Children's Choir Membership Form - Coral Gables Congregational United Church of Christ

My child is participating in the:*

Youth's Name*

First Last

Date of Birth*

MM

DD

YYYY

Age (this September)*

Height*

For Choir Robe.

Address*

Street Address Address Line 2 City State ZIP Code

Member Of*

Gables UCC

School You Attend*

Grade in School (this September)*

Instruments Played (if any):

Parents*

Email*

Home Phone

Work Phone

Cell Phone*

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.

Emergency Contact Information

First Contact Name*

First Last

Relationship to Child*

Home Phone

Cell Phone*

Second Contact Name

First Last

Relationship to Child

Home Phone

Cell Phone

Emergency Medical Information

Name of Health Insurance Company*

Policy Number*

*

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.

Authorized Pick-Up

Who can pick-up this child?*

Mother
Father

Note: We CANNOT forbid any parent access to their child without a Court Order.

The following individuals are authorized to pick-up my child:
Note: Siblings under 18 years of age CANNOT sign-in or sign-out children.

Name

First Last

Relationship to Child*

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Name

First Last

Relationship to Child

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Note: We reserve the right to refuse anyone access to your child whose name is not listed.

Parent's Digital Signature*

Date*

MM

DD

YYYY