Date(Required) Parents/GuardiansName of Parent or Guardian(Required) First Last Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Name of Other Parent or Guardian First Last Same address? Yes No Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneName of Alternate Contact Person(Required) First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone of Alternate Contact(Required)PermissionsDo we have permission to include your child’s or children's photograph in CCA publications, on the CCA website and in news releases? (Children will never be identified by name on the website.)(Required) Yes No Do you give your permission for your child or children to travel offsite and attend Heifer in Rutland, MA(Required) Yes No Do you give your permission for your child or children to travel offsite to Mills Apartment Luncheon in Milford, NH?(Required) Yes No Do you give your permission for Church volunteers to authorize emergency medical treatment provided by a licensed health care professional?(Required) Yes No Number Of Children12345First ChildName(Required) First Last Date of Birth(Required)Grade(Required)K1st2nd3rd4th5th6th7th8th9th10th11th12thHas he or she received a personalized Bible from the Church?(Required) Yes No AllergiesPlease explain (Food, medications, other)Name of DoctorCurrent MedicationsChronic Medical ConditionSecond ChildName(Required) First Last Date of Birth(Required)Grade(Required)K1st2nd3rd4th5th6th7th8th9th10th11th12thHas he or she received a personalized Bible from the Church?(Required) Yes No AllergiesPlease explain (Food, medications, other)Name of DoctorCurrent MedicationsChronic Medical ConditionThird ChildName(Required) First Last Date of Birth(Required)Grade(Required)K1st2nd3rd4th5th6th7th8th9th10th11th12thHas he or she received a personalized Bible from the Church?(Required) Yes No AllergiesPlease explain (Food, medications, other)Name of DoctorCurrent MedicationsChronic Medical ConditionFourth ChildName(Required) First Last Date of Birth(Required)Grade(Required)K1st2nd3rd4th5th6th7th8th9th10th11th12thHas he or she received a personalized Bible from the Church?(Required) Yes No AllergiesPlease explain (Food, medications, other)Name of DoctorCurrent MedicationsChronic Medical ConditionFifth ChildName(Required) First Last Date of Birth(Required)Grade(Required)K1st2nd3rd4th5th6th7th8th9th10th11th12thHas he or she received a personalized Bible from the Church?(Required) Yes No AllergiesPlease explain (Food, medications, other)Name of DoctorCurrent MedicationsChronic Medical ConditionCheck box to agree(Required) By checking here, you agree to release the Church, its employees and volunteers from any injuries sustained by your child, unless caused by the intentional misconduct of the person. Δ
