REGISTER FOR Conscious Contact youth group

We want to keep your child safe and comfortable during group meetings, so we'll need some information from you to be certain we know all we need to know to make the best experience for your child. Please complete the registration form below for your child. More than one child? Please complete a separate form for each.

Youth Name

First Name

Last Name

Date of Birth

YYYY

School Grade

Any Allergies or medical conditions we should be aware of?

Yes

If yes, please describe:

Mother's Name

First Name

Last Name

Father's Name

First Name

Last Name

Guardian's Name (if other than mother or father)

First Name

Last Name

Custody of Child

Both Parents

Mother Only

Father Only

Other

Please explain any custody issues that would prevent the child from being released to a parent

Parent/Guardian address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Parent/Guardian email

Youth email

By checking this box, you give us permission to seek immediate medical assistance for your chlld in the event of an emergency

Yes, I agree

No, I do not agree

Please list up to 4 people age 18 or over who are permitted to pick up your child from the church, PLEASE LIST THEIR RELATIONSHIP TO THE CHILD.

Youth Group Registration

REGISTER FOR Conscious Contact youth group

KEMBLE MEMORIAL UNITED METHODIST CHURCH