July 13-17, 2020

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 13-17, 2020.

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: _______

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

________________________________________________________________________

Child’s Name: __________________________________   Age:_______  Grade: _______

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

________________________________________________________________________

Child’s Name: __________________________________   Age:_______  Grade: _______

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

________________________________________________________________________