Children & Youth Registration Form 2025-2026 Program Year
Enroll your youth in Center Church activities!
Please fill out this form and click submit. If you are enrolling more than one youth, please submit a separate form for each of them.
Parent/Guardian Information
Name(s) of Parent(s)/Guardian(s)
*
Mailing Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Home Phone
Cell Phone
*
Email
*
This address will receive a confirmation email
Which role(s) would you be interested in if you were to volunteer with the Church School Program?
Please select all that apply.
Lead Disciple
Assisting Disciple (Shadowing)
Crafts
Music
Special Talent
Baking
Youth Information
Youth Name
*
Youth Gender
*
Please select all that apply.
Female
Nonbinary
Male
Youth Grade
*
Please select all that apply.
Pre-K
Kinder
1
2
3
4
5
6
7
8
9
10
11
12
Youth Date of Birth
*
Youth Photo Release
*
Please select all that apply.
Yes, I authorize pictures of my youth to potentially be included in church publications, including the church website.
No, I do not want pictures of my youth published.
Please indicate any learning challenges or other circumstances that teachers should know about your youth. What would help us teach them?
Youth Medical Information and Release
Has your Youth been fully vaccinated for Covid-19?
*
Please select all that apply.
Yes
No
Youth Allergies
Please explain any pre-existing or present medical conditions: (i.e.) Diabetes, asthma, motion sickness, physical disability, frequent colds, emotional/behavioral disability, sleep disturbances, stomach aches, seizure disorders, appliances (contact lenses, retainers, etc.)
Name, Dosage, and Frequency of any needed Medications
Primary Doctor Name and Phone Number
Preferred Hospital
If you have health insurance, list the Policy Number and Group Number here
If your child should require medical attentions for injuries received or illnesses contracted before any activity, please send us the necessary information to give him/her proper medical care during. his/her time with the youth ministry activity. I understand that in the event, medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency during the activities shown on this form, I hereby give my permission to the physician or dentist select by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary. I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. Coverage by the First Church of Christ, Hartford, through its accident policy will be used as a backup for what my family's insurance does riot cover. I understand all reasonable safety precautions will be taken at all times by the First Church of Christ, Hartford and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold the First Church of Christ, Hartford its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.
*
Please select all that apply.
Yes, I understand.
Electronic Signature
By typing your name here, you are signing this document
*
Today's Date
*
Submit
Description
Enroll your youth in Center Church activities!
Please fill out this form and click submit. If you are enrolling more than one youth, please submit a separate form for each of them.
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