2018-19 MCC Minor Registration Form
Effective Dates: September 1, 2018 – August 31, 2019
* Please complete a separate form for each child*
Child's First Name *
Your answer
Child's Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender
School *
Your answer
Grade *
Your answer
Known Allergies
Your answer
Medications that we should be aware of
Your answer
Any special conditions or other information you would like us to know about your child
Your answer
Home Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Guardian #1 Full Name *
Your answer
Guardian #1 Relationship to child *
Your answer
Guardian #1 Primary Phone *
Your answer
Type *
example: home, cell, work
Your answer
Guardian #1 Secondary Phone
Your answer
Type
example: home, cell, work
Your answer
Guardian #1 Email address *
Your answer
Guardian #2 Full Name
Your answer
Guardian #2 Relationship to child
Your answer
Guardian #2 Primary Phone
Your answer
Type
example: home, cell, work
Your answer
Guardian #2 Secondary Phone
Your answer
Type
example: home, cell, work
Your answer
Guardian #2 Email address
Your answer
Emergency contact #1 (other than parents/guardians) *
include full name, relationship, and contact info.
Your answer
Emergency contact #2 (other than parents/guardians)
include full name, relationship, and contact info.
Your answer
Physician
Name, Location & Phone # (Physician and Insurance information is optional. We would only use this information in an unlikely event where we would need to seek emergency medical attention for your child. This information will not be used in any other way.)
Your answer
Health Care Insurance Provider & Policy #
Your answer
PARENTAL CONSENT & RELEASE: This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Monadnock Covenant Church and it’s staff of any liability against personal losses of named child. (check all that apply) *
Required
Parent/Guardian Signature: (typed name counts as signature for consent and release if checked above) *
Your answer
Date of Signature: *
MM
/
DD
/
YYYY
Submit
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