Child's Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Name of Parent/Guardian 1 *

First Name

Last Name

Address of Parent/Guardian 1 *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 1 phone *

(###)

###

####

Name of Parent/Guardian 2

First Name

Last Name

Address of Parent/Guardian 2

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 2 Phone

(###)

###

####

EMERGENCY CONTACT PERSON

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Are you registering for Youth Group only?

Youth Group grade 6 though 12, usually meet on the First and second sunday of the month at 11:30 am (September -June)

Yes

No

Siblings attending?

Yes

NO

Photo release *

As the parent or guardian of the above mentioned child, I give Quincy Point Congregational Church the unrestricted right to publish and otherwise use photographic reproductions of likeness of my child/charge on its website, in the "To The Point" or Points Newsletters, social media and in marketing publications and/or community newspapers.

Yes

No