Child's Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's Name (Mom) *

First Name

Last Name

Parent's Phone (Mom) *

(###)

###

####

Cell or Home Phone? *

Cell

Home

Parent's Name (Dad) *

First Name

Last Name

Parent's Phone (Dad) *

(###)

###

####

Cell or Home Phone? *

Cell

Home

Food Allergies? Please Explain Below *

Yes

No

I/We give permission to Union Church to photograph the child listed above for use on the church website, literature and the church Facebook Postings. This release gives Union Congregational Church of Rockville rights to exhibit this work in print and electronic form publicly or privately. I understand there will be no financial or other remuneration for recording or photographing me or my children, either for initial or subsequent transmission or playback. *

Yes

No

Aside from the parents, please list who else will be allowed to take the child from the classroom at the end of the time. *

First Name

Last Name

First Name

Last Name

First Name

Last Name