Children & Youth Registration

Parent/Guardian 1 Name *

First

Last

Parent/Guardian 1 Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian 1 Preferred Phone *

Parent/Guardian 1 Preferred Phone is a:

Cell Phone
Home Landline
Work Phone

Parent/Guardian 1 Alternate Phone

Parent/Guardian 1 Alternate Phone is a:

Cell Phone
Home Landline
Work Phone

Parent/Guardian 1 Preferred Email *

Parent/Guardian 2 Name *

First

Last

Parent/Guardian 2 Address (if different than Parent/Guardian 1)

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian 2 Preferred Phone

Parent/Guardian 2 Preferred Phone is a:

Cell Phone
Home Landline
Work Phone

Parent/Guardian 2 Alternate Phone

Parent/Guardian 2 Alternate Phone is a:

Cell Phone
Home Landline
Work Phone

Parent/Guardian 2 Preferred Email

Child's Name *

First

Last

Child's Nickname (optional)

Child's Birthday *

Child's Age *

Child's Grade *

Child's School

Please note any allergies or special needs:

Do you have an additional child to register? (1) *

Yes
No

Child's Name *

First

Last

Child's Nickname (optional)

Child's Birthday *

Child's Age *

Child's Grade *

Child's School

Please note any allergies or special needs:

Do you have an additional child to register? (2)

Yes
No

Child's Name *

First

Last

Child's Nickname (optional)

Child's Birthday *

Child's Age *

Child's Grade *

Child's School

Please note any allergies or special needs:

Do you have an additional child to register? (3)

Yes
No

Child's Name *

First

Last

Child's Nickname (optional)

Child's Birthday *

Child's Age *

Child's Grade *

Child's School

Please note any allergies or special needs:

Is the child or children you are registering in nursery - 5th grade? *

Yes
No

Permission for Participation (Child) *

I hereby give permission for the child/children listed to participate in activities or programs offered by Rock Spring Congregational UCC’s Sunday School program that are held at the church or for which the church will provide transportation.

I give my permission.

COVID-19 Guidelines (Child) *

I understand that in-person gatherings will be governed by Rock Spring Congregational UCC’s COVID-19 guidelines. I agree that my child will follow the guidelines (including wearing of masks and social distancing) and will not participate if they or a member of their family are/have been experiencing symptoms of COVID-19 or have tested positive within the past 10 days.

I give my permission.

Photography Release (Child) *

I give permission for pictures of my child/children to be used in communications internal to Rock Spring including Rock Spring News, All Church Email, TW@RS emails, and posters that may be placed on the premises. I understand that my child/children’s name(s) may be used in association with these types of communications.

I give my permission.
I do not give my permission.

Photography Release 2 (Child) *

I give permission for pictures of my child/children to be used on social media sites that the church maintains, namely Facebook and the Rock Spring website. I understand that my child's name will never be used in these types of communication.

I give my permission.
I do not give my permission.

Is the child or children you are registering in 6th - 12th grade? *

Yes
No

Permission for Participation (Youth) *

I hereby give permission for the individual(s) listed to participate in activities or programs offered by Rock Spring Congregational UCC’s Youth of Rock Spring program that are held via Zoom, at the church*, or for which the church will provide transportation*. I also authorize the Adult Leaders and Chaperones to sign as the responsible adult for the above-listed child/children in connection with third party recreational providers such as ski, canoe, kayak outfitters, or transportation providers.

I give my permission.

COVID-19 Guidelines (Youth) *

I understand that in-person gatherings will be governed by Rock Spring Congregational UCC’s COVID-19 guidelines. I agree that my youth will follow the guidelines (including wearing of masks and social distancing) and will not participate if they or a member of their family are/have been experiencing symptoms of COVID-19 or have tested positive within the past 10 days.

I give my permission.

Photography Release 1 (Youth) *

I give permission for pictures of my child/children to be used in communications internal to Rock Spring including Rock Spring News, All Church Email, TW@RS emails, and posters that may be placed on the premises. I understand that my child/children’s name(s) may be used in association with these types of communications.

I give my permission.
I do not give my permission.

Photography Release 2 (Youth) *

I give permission for pictures of my child/children to be used on social media sites that the church maintains, namely Facebook and the Rock Spring website. I understand that my child's name will never be used in these types of communication.

I give my permission.
I do not give my permission.

Insurance Company (Youth) *

Policy/Group Number (Youth) *

Primary Care Physician (Youth) *

Phone Number of Primary Care Physician (Youth) *

Permission to Treat (Youth) *

I hereby give permission for any necessary emergency medical treatment to be administered at the discretion of the group leaders or trained medical professionals, and for any health care information to be shared with the same. I also accept any and all financial obligations that arise from such treatment. I hereby waive Rock Spring Congregational UCC and any event leaders from liability in the case of an emergency.

I give my permission.

Is there any other information that would assist us in working with your child(ren)?

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Children & Youth Registration