Children/Youth Registration Form – First Congregational UCC Boulder

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Your Full Name:

Child/Youth's Preferred Name:

Pronouns:

Grade in Fall 2024:

Date of Birth:

Youth Email:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian Name:

Primary Email:

Primary Phone:

Parent/Guardian Name:

Email:

Phone:

Please List Other Children in the Family:

Aware Parent/Guardian

Dietary Restrictions:

Other Concerns/Difficulties that Teachers Should Be Aware Of?

Emergency Contact Name (not a parent/guardian):

Emergency Contract Phone: