YOUTH INFORMATION FORM 2021

First Congregational Church in Winchester

21 Church Street Winchester MA 01890

(781)729-9180
YOUTH INFORMATION FORM

For middle school and high school students
This form requests contact and medical information for use throughout the current school year for youth participating in the First Congregational Church in Winchester youth programs and activities. Information provided in this document will be kept on file at the church and transported with youth leaders and chaperones to off-site trips. Should any of this information change over the course of the school year, please contact the Youth Minister.
Youth's Name:

First NameLast Name
Youth's Cell Phone #:
Youth's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Youth's Email Address:
example@example.com
Youth's Birthdate:

MonthDayYear
Date
School Attending:
HS Graduation Year:
Home Phone #:
Parent/Guardian Name

First NameLast Name
Parent/Guardian Cell Phone #:
Parent/Guardian Email Address:
example@example.com
Emergency Contact Name and Phone # in case parents/guardians cannot be reached:
Youth's Doctor's name and Phone #:
Health Insurance Company Name:
Health Insurance Policy #:
PLEASE SELECT ONE OR MORE OF THE FOLLOWING OPTIONS

Send all communications to parents/guardians only and we will forward to our youthSend all communications to both parents/guardians and youthSend all communications to youth only (do not cc parents/guardians)
Health concerns, physical limitations, allergies, etc.:
Health concerns, physical limitations, allergies, etc.:
In order to share the good news of the ministries of the church, we sometimes take photos of children and youth for use on bulletin boards, in our newsletters and on our website. When published on our website we do not include any identifying information (name, address, etc.) about the child along with thephoto. Do you authorize the use and reproduction of your child(ren)'s photo(s) by the church?
Please share any additional information you would like:
If there are other concerns or information not included on this form that you wish us to know, please contact a minister.
Should be Empty: