Church School Registration Form
(Print and complete this form. Send to church office or bring to child’s class)

Family Name: ___________________________________________________

Street Address: __________________________________________________

Town, Zip Code: __________________________________________________

Phone No: __________ Email Address__________________

I would like to receive the weekly E-Torch (circle choice) Yes or No

Child’s Name: ____________________________________________________

Age: ________ Grade:________Birth Date: ________________

Child’s Name: ____________________________________________________

Age: ________ Grade:_______ Birth Date: ____________________

Child’s Name: ________________________________________________

Age: ________ Grade:________ Birth Date: ______________

Parent’s or Guardian’s Names: _______________________________

Important information: (Continue on back if more space is needed.)

Allergies:___________________________________________________________

Talents: musical instruments, dance, theatre, etc. ______________________________

Indicate Parent’s Interest in helping with church school, children’s choirs, Pursuit, special events.
____________________________________________________________________

Web Photos:

United Church occasionally places photographs on our web page (www.unitedwalpole.org) to highlight the church’s activities. Names and other personal identifying information are not included with any pictures so displayed. However, if you prefer that pictures including your child not be placed on the UCW web site, please so indicate below.

_____ I do not want or give United Church in Walpole permission to display pictures that include my child on the UCW web-site.

Child’s Name: ______________________________________
Parent’s Signature:___________________________________
Date:_____________________________________________