Please sign up in advance to make drop off quick and easy!

Emergency Contact Information

First Name (required):
Last Name (required):

Address


Home Phone:
Cell Phone:
Email:

Spouse/Partner Information, if applicable:

First Name:
Last Name:
Cell Phone:
Email:

Child/rens' Information:

Full name and birthdate for each child



In Case of Emergency:

In case of emergency, if the above cannot be located:
1st Choice:
2nd Choice:


Medical Information (required)

Insurance?  Yes No
Insurance Company:
Policy Number(s):
I/we hereby give permission for my child(ren) to eat the following snacks:
 Teddy Grahams Goldfish Cheerios Juicy Juice box
Allergies (be sure to include food allergies)
Please identify any medical issues/medications that the adult leadership needs to be aware of or that may be pertinent in an emergency situation:

Medical Release (required)

 I/we authorize an adult, in whose care the minor has been entrusted, to consent to any x-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. I/we are liable and agree to pay all costs and expenses incurred in connection with such medical or dental services rendered to the aforementioned child(ren) pursuant to this authorization. Should it be necessary for my/our child(ren) to return home from an off-site event due to medical reasons or otherwise, I/we shall assume all transportation costs.


Photo Release

I/we give permission for First Church of Christ Congregational, West Hartford to use my/our child(ren)'s name and photographic likeness in all forms and media for advertising, trade, and other lawful purposes.
 Yes No


Parent Consent (required)

 I/we give permission for my/our child(ren) to attend and participate in the First Church of Christ Congregational, West Hartford Babysitting Fundraiser.

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