Child Info Form (2025-2026)
Canonsburg UP Church
Child's Name
First Name
Last Name
Age
Birthdate
-
Month
-
Day
Year
Date
Parent/Guardian (1) Name
First Name
Last Name
Parent/Guardian (1) Cell
Please enter a valid phone number.
Parent/Guardian (2) Name
First Name
Last Name
Parent/Guardian (2) Cell
Please enter a valid phone number.
In Case of Emergency, please contact:
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
In addition to you, the parent/guardian listed above, please list up to 3 names of adults or relatives (must be 14 years or older) who have your permission to pick up your child.
Pick Up Person 1
First Name
Last Name
Pick Up Person 2
First Name
Last Name
Pick Up Person 3
First Name
Last Name
Are there any allergies, health problems/adaptations needed? If yes, please explain and include any medications they will have.
I give permission for my child to be photographed and their picture to be used in church correspondence/promotion including social media.
Yes
No
Parent Signature (Please Print Below)
Child's Grade
Name of School Attending
Please fill out any applicable information below that might help us to get to know your child.
Do you have any special instructions regarding snacks? If yes, please explain.
Is your child toilet trained?
Yes
No
Siblings Name(s) and Age(s)
Hobbies/Activities your child enjoys or is involved in:
Does your child have a pet?
Yes
No
If yes, what kind and name?
What are some things that comfort your child?
What are some things that frighten your child?
Anything else you'd like us to know about your child.
Submit
Should be Empty: