2026-2027 YOUTH CONNECT/X-FACTOR SIGN UP

Community Baptist Church of Englewood

224 First Street

Englewood, NJ 07631

Phone: 201-568-6369 Fax: 201-568-3512 www.cbcofe.org

Reverend Dr. Lester W. Taylor, Jr., Senior Pastor

**Please note: Children are placed in classes by Grade, NOT by Age. All Pre-K must be potty trained.**

CBC YOUTH CONNECT & X-FACTOR SIGN UP FORM

2026-2027

AGES 3-17

Student's Name:

First NameLast Name

Grade 2025/2026 School Year

Age:

Gender:

Date of Birth:

MonthDayYear

Does your child have any special educational needs (example: IEP/504)?

If yes please specify:

List any allergies or food allergies:

Student's Name:

First NameLast Name

Grade 2026/2027 School Year

Age:

Gender:

Date of Birth:

MonthDayYear

Does your child have any special educational needs (example: IEP/504)?

If yes, please specify:

List any allergies or food allergies:

Address:

Street Address

Street Address Line 2

CityState

Zip Code

Parent/Guardian's Name:

First NameLast Name

Contact Telephone #:

Area CodePhone Number

E-mail

example@example.com

2nd Parent/Guardian's Name:

First NameLast Name

Contact Telephone #:

Area CodePhone Number

E-mail

Emergency Contact Information:

Emergency Contact Name:

First NameLast Name

Telephone #:

Area CodePhone Number

Indicate any special custody arrangements:

Please list at least 2 additional persons authorized to pick up your child:

Authorized Person for Pick-Up:

First NameLast Name

Relationship:

Authorized Person for Pick-Up:

First NameLast Name

Relationship:

Consent for Participation in CBC Youth Connect & XFactor

I hereby consent for my child to participate in Community Baptist Church of Englewood (CBC) Youth Connect/X-Factor 2026/2027 and agree that my child and I will adhere to the protocols and policies of CBC during all activities. I hereby consent for CBC to secure and authorize emergency medical treatment for the above named child in the event of an emergency.

Please indicate your agreement by checking the box:

Photo Release

For valuable consideration received, I hereby grant Community Baptist Church of Englewood, its representatives, licensees, and assigns, the right and unrestricted permission to use my photo including, but not limited to use in any and all of its publications, including website entries, without payment or other consideration.

I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby hold harmless, release and forever discharge Community Baptist Church of Englewood, its representatives, licensees, and assigns from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have but for this authorization.

I am 18 years of age and am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.

Please indicate your agreement by checking the box:

Walk Home Authorization for Children Ages 13-17

My child named above has my permission to leave CBC 2026-2027 without an adult escort. I understand that CBC and its staff are not responsible for my child's safety after their departure. Walkers/bikers are not to leave before their class is dismissed unless a signed note has been sent by the parent/guardian stating the exact time the child is to leave.

Please indicate your agreement by checking the box: