Office Use: Date Received: _____Entered in Database: ______
Registration Form PreK-8th Grade
Parent/Guardian Name: ______________________
Cell Phone: _______________________
Parent E-mail Address: __________________________________________________________________
Mailing Address with Zip Code: ____________________________________________________________
Home Phone Number: ______________________
Parent/Guardian Name: ______________________
Cell Phone: _______________________
Parent E-mail Address: __________________________________________________________________
Mailing Address with Zip Code: ____________________________________________________________
Home Phone Number: ______________________
Emergency Contact: ______________________
Cell Phone: _______________________
E-mail Address: ________________________________________________________________________
Mailing Address with Zip Code: ____________________________________________________________
Home Phone Number: ______________________
Child Name: ______________________
Preferred Name: ______________________
Birthday: ______________________
Age: _____________ Grade: ______________________
Allergies/medications/medical conditions/dietary restrictions: _______________________________________________
Check if Yes: Baptized ☐
New to Church☐
Confirmed ☐
Church Member ☐
Check all that apply for this child:
Sunday Morning Programming (PreK-8th) ☐ Cherub Choir (0-5yrs) ☐ Junior Choir (5yrs-4th) ☐
Gospel Choir (6th-12th) ☐ Gospel Choir (6th-12th) ☐ Youth Group (5th-12th) ☐
Child Name: ______________________
Preferred Name: ______________________
Birthday: ______________________
Age: _____________ Grade: ______________________
Allergies/medications/medical conditions/dietary restrictions: _______________________________________________
Check if Yes: Baptized ☐
New to Church☐
Confirmed ☐
Church Member ☐
Check all that apply for this child:
Sunday Morning Programming (PreK-8th) ☐ Cherub Choir (0-5yrs) ☐ Junior Choir (5yrs-4th) ☐
Gospel Choir (6th-12th) ☐ Gospel Choir (6th-12th) ☐ Youth Group (5th-12th) ☐
Child Name: ______________________
Preferred Name: ______________________
Birthday: ______________________
Age: _____________ Grade: ______________________
Allergies/medications/medical conditions/dietary restrictions: _______________________________________________
Check if Yes: Baptized ☐
New to Church☐
Confirmed ☐
Church Member ☐
Check all that apply for this child:
Sunday Morning Programming (PreK -8th) ☐ Cherub Choir (0-5yrs) ☐ Junior Choir (5yrs-4th) ☐
Gospel Choir (6th-12th) ☐ Gospel Choir (6th-12th) ☐ Youth Group (5th-12th) ☐
Child Name: ______________________
Preferred Name: ______________________
Birthday: ______________________
Age: _____________ Grade: ______________________
Allergies/medications/medical conditions/dietary restrictions: _______________________________________________
Check if Yes: Baptized ☐
New to Church☐
Confirmed ☐
Church Member ☐
Check all that apply for this child:
Sunday Morning Programming (PreK -8th) ☐ Cherub Choir (0-5yrs) ☐ Junior Choir (5yrs-4th) ☐
Gospel Choir (6th-12th) ☐ Gospel Choir (6th-12th) ☐ Youth Group (5th-12th) ☐
Additional Information for Youth Group Registration (Grades 5-12 only)
Is there any other information that is important for activity leaders to be aware of?
I hereby certify that I am aware of, approve of, and take full responsibility for the participation of the above named
Participants in Memorial Congregational Church of Sudbury’s Children and Youth Programming. Furthermore, I assume all
risk of and financial responsibility for any loss or injury to the youth or others that may occur as a result of negligence or
misconduct by the youth, and I release the Church, and its employees, volunteers, and other agents, from any and all
responsibility and legal liability for loss, damage, or injury to the person or property of the Youth which may be sustained
during or as a result of participation in the Youth Group.
In the event of an emergency, including illness, injury, or incapacity suffered by the Youth during the course of the
programming, I hereby authorize the Youth Group Leader, a chaperone, or any other adult leader to act as agent for me in
consenting to any reasonably necessary X-Ray examination, medical, dental, surgical, or psychological diagnosis,
treatment, and/or care, advised and supervised by a physician, dentist, surgeon, psychologist, or social worker licensed to
practice under the laws of the state in which the services are rendered. I understand that I, or the applicable insurance
carrier(s), will be financially responsible for any such emergency services. I expect that attempts will be made to contact me
in the event of any such emergency.
Signature of Parent/Legal Guardian:
Date: