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