Parent/Guardian (1) *

First Name

Last Name

Phone

(###)

###

####

Parent/Guardian (2)

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child 1 *

First Name

Last Name

Child 1: Date of Birth *

MM

DD

YYYY

Child 2

First Name

Last Name

Child 2: Date of Birth

MM

DD

YYYY

Child 3

First Name

Last Name

Child 3: Date of Birth

MM

DD

YYYY

Child 4

First Name

Last Name

Child 4: Date of Birth

MM

DD

YYYY

Do you have more then 4 children? *

If yes, please fill out another registration form for additional children.

Yes

No

In case of medical emergency, I give permission for the volunteers at Storrs Community Church to obtain medical treatment for my child(ren). *

Yes

No

I give permission for my child(ren) to be photographed or videotaped during Storrs Community Church activities. I recognize that images may be used on SCC publications, website or social media. *

Yes

No

I have read the SCC Safe Church Policy and by checking the box, sign and indicate my agreement with its terms. I agree that checking the box will be the electronic representation of my signature for all purposes on this document. *

Yes

No