Sunday School Registration Form

Northside UMC Sunday School Registration Form

2009-2010

Please print out this form, fill out one form (2 pages) per student and return to Evy Nickerson or the Church office.

Please print all information.

Student’s Name: _____________________________________________________________________________

Age: _____ Gender: ____________ Grade (entering 2009): _______________ Birthday: __________________

Mailing Address: _____________________________________________________________________________

Residential Address (If different from Mailing): ______________________________________________________________________________________

Parent/Guardian’s Name’s:

______________________________________________________________________________________

Home Phone: ________________________ Primary Cell Phone: ______________________________

Parent/Guardian’s Email Address: _______________________________________________________

Emergency and Health Information

Emergency Contact (other than Parent/Guardian): ____________________________________________________

Phone Number: ______________________________________________

Relation to student: ___________________________________________________

Student’s Insurance Company _____________________ Policy # ____________________________

Family Physician _______________________________ Phone # ____________________________

Allergies and Medical Conditions

Allergies: _____________________________________________________________________________

Medications: __________________________________________________________________________

Past Medical History: ___________________________________________________________________

Food Allergies: ________________________________________________________________________

Operations/Serious Injuries: _____________________________________________________________

Chronic/Recurring Illness: _______________________________________________________________

Tetanus (approximately last date of booster shot): __________________________________________

If your child has the following please fill in the circle and list beside it the treatment:

O Asthma _________________________________________________________________________

O Diabetes ________________________________________________________________________

O Seizures ________________________________________________________________________

O Other: __________________________________________________________________________

Other Concerns: _________________________________________________________________________

Does your child have any special needs, behavioral problems or learning disabilities:

____________________________________________________________________________________________

If you have any additional information concerning your child that would be useful to Sunday School Teachers and staff or if you would like to go into further detail please staple it to your registration form with the child’s name at the top.

Northside UMC Photo Consent

I, the undersigned, grant my permission to Northside UMC of Brewster, Massachusetts to photograph/Film my child (print name)

______________________________________________________________________________________

with the understanding that his or her photo may be displayed in any publications, multimedia production, display, and advertisement or on the World Wide Web publication only in connection with promoting Northside UMC programs. I release and forever discharge the Northside UMC of Brewster, Massachusetts from any and all claims and demands arising out of or in connection with the use of said photographs/images/film.

Printed Name of Parent/Guardian: ________________________________________________________

Signature of Parent/Guardian: ___________________________________________________________

Date: __________________________________________________

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I, the undersigned, do not grant permission for Northside UMC of Brewster, Massachusetts to photograph/film my child.

Printed Name of Parent/Guardian: _______________________________________________________

Signature of Parent/Guardian: __________________________________________________________

Date: __________________________________________________

Reviewed by:

Evelyn Nickerson (Director of Children and Youth Ministries) Date

______________________________________________________________________________________