Registration Form – June 27-July 1, 2022

Parent/Guardian Name(s) ____________________________________________________

Address: _________________________________________­­­________________________

Phone:­­­___________________________________________________________________

Email: ­­­­­­­­­­­­­­­­­___________________________________________________________________

I, _______________________________________, the custodial parent/guardian for ____________________________,

give permission for my child/children to participate in  Make a Difference Week, July 26-30, 2021.

Parent or Guardian Signature: _______________________________________________

Date: _________________

I give permission for my child/children’s photo (without his/her name) to be shown on Central Congregational

Church’s bulletin boards, Facebook page, and website.     Yes ____     No ____

Child’s Name: __________________________________   Age:_______  Grade in Sept.: _______

Does your child have allergies? (i.e.: food or medicine)

________________________________________________________________________

Child’s Name: __________________________________   Age:_______  Grade in Sept.: _______

Does your child have allergies? (i.e.: food or medicine)

________________________________________________________________________

Central Congregational Church

PO Box 339,  One Worthen St., Chelmsford MA 01824

978-256-5931   office.admin@cccchelmsford.org