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 attend Make a Difference Week, June 27 – July 1, 2022. I understand that my child/children will receive the utmost care; however, in the event of an emergency, I authorize those volunteering on behalf Central Congregational Church to seek and obtain medical care for my child/children.
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 ____
Emergency contacts if the above parent/guardian cannot be reached.
1st Emergency Contact: ____________________________ Phone:___________________
2nd Emergency Contact: ____________________________ Phone:___________________
Please list everyone who is allowed to pick up your child/children.
________________________________________________________________________________________________________________________________________________
Child’s Name: __________________________________ Age:_______ Grade: _______
T-Shirt Size (circle one) – Youth Sm Youth Med Youth Lg Youth XL
Adult Sm Adult Med Adult Lg Adult XL Adult XXL
Do we need to know anything about your child’s health to ensure his/her safety? (e.g. uses an inhaler, has seizure disorder, special needs etc.)
________________________________________________________________________
Does your child have allergies? (i.e.: food or medicine)
________________________________________________________________________
Child’s Name: __________________________________ Age:_______ Grade: _______
T-Shirt Size (circle one) – Youth Sm Youth Med Youth Lg Youth XL
Adult Sm Adult Med Adult Lg Adult XL Adult XXL
Do we need to know anything about your child’s health to ensure his/her safety? (e.g. uses an inhaler, has seizure disorder, special needs etc.)
________________________________________________________________________
Does your child have allergies? (i.e.: food or medicine)
________________________________________________________________________
Child’s Name: __________________________________ Age:_______ Grade: _______
T-Shirt Size (circle one) – Youth Sm Youth Med Youth Lg Youth XL
Adult Sm Adult Med Adult Lg Adult XL Adult XXL
Do we need to know anything about your child’s health to ensure his/her safety? (e.g. uses an inhaler, has seizure disorder, special needs etc.)
________________________________________________________________________
Does your child have allergies? (i.e.: food or medicine)
________________________________________________________________________