ChristianEdRegistration2017 2018

Registration for Christian Learning
Program
2017-2018 Program Year
First Congregational Church of Evanston, UCC

1417 Hinman Avenue
Evanston, IL 60201
847-864-8332
FCCE strives to create a learning environment where children can deepen their relationship to God, speak
openly, be supported and learn to listen to their hearts. We hope your whole family will engage with us on this
journey. Please complete one family information page and a separate participant page for each child. This info
will be shared with the FCCE Christian Learning Program staff and volunteer teacher team to best support your
child(ren):
Family Information (Please complete one per family)
Parent/Guardian 1:______________________________________________________________
First M.I. Last
Phone: _________________________________________________________________________
Home Cell
Address: _______________________________________________________________________
Street
________________________________________________________________________
City State Zip
Email: ________________________________________________________________________
Parent/Guardian 2:______________________________________________________________
First M.I. Last
Phone: _________________________________________________________________________
Home Cell
Address: _______________________________________________________________________
Street
________________________________________________________________________
City State Zip
Email: ________________________________________________________________________
Emergency Contact Information

Name: _________________________________________________________________________
First M.I. Last
Phone: _________________________________________________________________________
Home Cell
Relationship to Participant: _________________________________________________________
Insurance Provider:______________________________________________________________
Subscriber Name: __________________________ Policy Number: _______________________

Participant Page (Please complete one for each child or infant)
Childs Name: __________________________________________________________________

First M.I. Last
Preferred Name: _____________________ Date of Birth: ___________________ Grade: _______

month/day/year
Primary Address: Same as Parent/Guardian 1 Same as Parent/Guardian 2
School Name (or write nursery): _____________________________________________________
Is your child allergic to any food, medications, materials or insects? Yes ____ No _____
_______________________________________________________________________________
If yes, please list
Does your child have any medical conditions or carry any medication? Yes ____ No _____
_______________________________________________________________________________
If yes, please list
Please describe your childs strengths and interests: _____________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Please describe your childs learning style and any special needs: __________________________
_______________________________________________________________________________
What do you hope your child gains by enrolling her/him in this years program?: _______________
_______________________________________________________________________________
_______________________________________________________________________________
Please list all persons (other than parent/legal guardian) authorized to pick up your child:
______________________________________________________________________________
Name Relationship to Child
______________________________________________________________________________
Name Relationship to Child
I authorize my child to walk home independently from programming: Yes _____ No _____
------------------------------------------------------------------------
Do you authorize First Congregational Church of Evanston UCC to use photos of your child in church
media (ex. website, Facebook, newsletter)? (Names will not be used) Yes _____ No _____
Parent/Guardian: _________________________________________________________________
Print Signature Date

ChristianEdRegistration2017 2018

Uploaded by

Copyright:

Available Formats

ChristianEdRegistration2017 2018

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

ChristianEdRegistration2017 2018

Uploaded by

Copyright:

Available Formats

Registration for Christian Learning

First Congregational Church of Evanston, UCC

Family Information (Please complete one per family)

Emergency Contact Information

Relationship to Participant: _________________________________________________________

Subscriber Name: ____ Policy Number: _

Childs Name: __________________________________________________________________

Preferred Name: _________ Date of Birth: _ Grade: _

Primary Address: Same as Parent/Guardian 1 Same as Parent/Guardian 2

School Name (or write nursery): _____________________________________________________

Please describe your childs strengths and interests: _____________________________________

You might also like