Fall 2009 Youth Program Registration Form

Youth Program Registration 2009-2010 Name of youth____________________________________________________________________ Age of youth _______________ Birthday_________________________ Grade ________________ Youth’s Cell phone______________________ Youth’s Email address ________________________ Name(s) of parent(s) or Guardian(s)__________________________________________________ Address_________________________________________________________________________ Home phone__________________________ Cell phone(s)________________________________ Work phone(s)____________________________________________________________________ Email address(es) ________________________________________________________________ Please list any medical conditions or allergies that leaders should be aware of: _______________________________________________________________________________ _______________________________________________________________________________ Name of Sibling(s) in the church: ___________________________________________________ Age(s) & Grade(s): _______________________________________________________________ Local person to contact if parent(s) cannot be reached in emergency: Name: _________________________________________________________________________ Phone number(s): _______________________________________________________________ Relationship: ___________________________________________________________________ “In case of emergency due to serious illness or injury when I cannot be contacted, I give my permission to staff and volunteers of First Congregational Church of Santa Cruz to authorize emergency medical or dental attention for my child.” Doctor: _________________________________________ Phone: ________________________ Dentist: _________________________________________ Phone: ________________________ “I give permission for the above named youth to participate in the Youth Program of First Congregational Church of Santa Cruz during the current program year.” Parent or Guardian Signature: ____________________________________Date: _____________ Parent or Guardian Printed Name: ___________________________________________________ Fall 2009 Sunday Youth Program Registration Form.doc