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