Registration

We are thrilled your child or teen will be joining us for one or more of our events, programs, groups or classes this year!

Please fill out and submit a form for each child in your family. Required fields are marked with a (*). The volunteer section only needs to be filled out once per family.

Don’t want to fill out the form online? Print a copy and either mail it to the church office or bring it to the next youth group or youth event.

Basic Information

Child/Teen's Full Name* (First, MI, Last)

Preferred Name/Nick Name

Date of Birth* (mm/dd/yy)

Age*

School Grade Entering*

Parent(s)/Guardian(s) Name(s)*

Parent(s)/Guardian(s) Email(s)*

Street Address*

City, State, Zip*

Home Phone*

Cell Phone(s)

Emergency Contact 1 Name & Phone*

Emergency Contact 2 Name & Phone (Optional)

For teens 6-12th grade, please include the following if applicable:
Youth's Cell Phone & Email (Optional)

Medical Information

Please Describe Any Allergies


Please List Any Medications


Please List Any Existing Medical Conditions or Physical Limitations

Last Tetanus (mm/yy)

Contact Lenses

Family Physician Name & Phone*

Family Physician Address

Insurance Company*

Name on Insurance*

Insurance Policy Number*

Additional Information

Educational/Learning Considerations:
What should our teachers or youth leaders know

Permissions and Consents

1.* I, (parent/guardian name), parent/legal guardian of (child's name), hereby give my child permission to participate in all church-sponsored youth activities taking place during the 2013-2014 school year. I accept 

2.* I release the Congregational Church in Exeter, its staff and volunteers, from responsibility and liability for an injury or illness my child may sustain during church-sponsored activities. In the event of an emergency, I hereby authorize as temporary guardian, Jennifer Daysa, Director of Youth and Family Ministries, or any other church-approved leader to consent in my absense and the absence of other legal guardians, to an x-ray examination, medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor's office or in a hospital. I expect to be contacted as soon as possible. I accept 

3. (Optional) I give permission for my child to have his/her picture taken for part of the program and possible display on builetin boards, church publications, and the church website/facebook pages without his/her name. I accept 

4. (Optional) I give permission for my child/teen to have special arrangements/instructions for pick-up/departure from church school or youth events. I accept 

5. (Optional) (If child is an infant or toddler) I give permission for my child to have his/her diaper changed by staff and/or volunteers in the nursery. Please check to confirm your permission I accept 

*Required Fields