Youth Registration | Norwalk Christian Church

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Norwalk Christian Church

(Disciples of Christ)

Youth First name:

Youth Last name:

Youth Date of Birth:

Month

Day

Year

Youth Home Address:

Grade:

T-Shirt Size:

Special Conditions, Disabilities, Allergies, or Any other Information:

Parent/ Legal Guardian Information

Parent/ Legal Guardian Name:

Address:

Phone:

Email:

Parent/ Legal Guardian Name:

Address:

Phone:

Email:

Emergency Contact (Other than Parent/Guardian)

Name:

Phone:

Name:

Phone:

Pick-Up Authorization

The following people are authorized to pick up my child from youth events:

Name:

Phone:

Name:

Phone

Name:

Phone

(Note: Anyone not listed will not be permitted to pick up your child without your permission)

Photo/Video Permission

Please select below

Parent/Legal Guardian Consent

By submitting this form, I give permission for my child to participate in the youth programs at Norwalk Christian Church.

Signature

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Date

Month

Day

Year

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