Confirmation Form - Deep River First Congregational Church

First Name*

Middle Name*

Last Name*

Preferred Name

Date of Birth*

Confirmation Cell

Confirmand's Email

Name of School*

Grade*

Baptism*

Baptized

Not Baptized

List others who are authorized to pick up child from class.

List ALL allergies to include food, bees, etc. If none, type N/A*

Additional information (medications needed, limitations, etc.)

PARENT/GUARDIAN INFORMATION

Mother/Guardian Full Name

Mother/Guardian Cell Phone Number

Mother/Guardian Email

Mother/Guardian Street Address

Mother/Guardian Town

Mother/Guardian Zip Code

Father/Guardian Full Name

Father/Guardian Cell Phone Number

Father/Guardian Email

Father/Guardian Street Address

Father/Guardian Town

Father/Guardian Zip Code

Which address is the youth primary residence?

Family Church Relationship

Members

Friends

Wish to join church

EMERGENCY CONTACT INFORMATION

Emergency Contact Name*

Emergency Contact Phone*

PARENT/GUARDIAN PERMISSION

Photography Permission*

Yes, I give permission as noted below

Yes, I give permission as noted below, but face needs to be blurred before publication

No, I don't give permission

Other

I give permission to The First Congregational Church of Deep River to take pictures/video of my child(ren) during Church wide activities, which could be used for church purposes to include but not limited to the Church website, The Messenger, picture disks, social media, power point presentations and the local newspaper. Full names of the child will NOT be published. Parents should be aware the worship service is live-streamed. If you don't want your child to be seen on the live-stream, please speak to our minister or the Director of Christian Education.

Name of person consenting/submitting form*

Relationship to Registered Confirmand*

Date*

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