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Child's Name *
Child's Name
Date of Birth
Date of Birth
Address *
Address
Parent's Name (Mom) *
Parent's Name (Mom)
Parent's Phone (Mom) *
Parent's Phone (Mom)
Cell or Home Phone? *
Parent's Name (Dad) *
Parent's Name (Dad)
Parent's Phone (Dad) *
Parent's Phone (Dad)
Cell or Home Phone? *
Food Allergies? Please Explain Below *
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. *
Aside from the parents, please list who else will be allowed to take the child from the classroom at the end of the time. *
Aside from the parents, please list who else will be allowed to take the child from the classroom at the end of the time.