2009-2010 Children / Youth Registration Form

    The First Congregational Church of Canton Center 
Canton Center, CT

Click HERE for a printable form for mailing

 Please list all children who plan to attend, Infants - Grade 12:
     ( Fields with * are required.)

1) Child's Name * M    F  * Birthdate: *
     Age*     yrs Grade * Baptized?     Y  N *
2) Child's Name M    F  Birthdate: 
  Age   yrs Grade   Baptized?     Y N
3) Child's Name M    F    Birthdate: 
   Age   yrs Grade   Baptized?     Y N
4) Child's Name M    F    Birthdate: 
    Age   yrs Grade   Baptized?      Y  N

   * Parent/Guardian's Name (primary contact):     

   * Address:  

   * Home Phone:              

   Business Phone:      

    * E-Mail:  

     Parent/Guardian's Name (secondary contact -optional):   

    Address:  

    Home Phone:              

    Business Phone:        

    E-Mail:  


                In case of emergency, please contact:

                        Name:      Relationship:         Phone:              

     Allergies, including food, or other conditions that may affect your child(ren)'s participation, or other comments:

Name of Physician:      Phone: