ChristianEdRegistration2021 2022.docx 2
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First Congregational Church of EvanstonChristianEdRegistration2021 2022.docx 2
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First Congregational Church of EvanstonRegistration for Christian Learning Program
2021-2022 Program Year
First Congregational Church of Evanston, UCC
1417 Hinman Avenue
Evanston, IL 60201
847-864-8332
FCCE strives to create a learning environment where children can deepen their relationship with God, speak
openly, be supported & learn to listen to their hearts. We hope your whole family will engage with us on this
journey. Please complete one family info page and a separate participant page for each child. This info will be
shared with the FCCE Christian Learning Program staff and volunteer teacher team to best support your child(ren):
Family Information (Please complete one per family)
Parent/Guardian 1:______________________________________________________________
First M.I. Last
Phone: _________________________________________________________________________
Home Cell
Address: _______________________________________________________________________
Street
________________________________________________________________________
City State Zip
Email: ________________________________________________________________________
Parent/Guardian 2:______________________________________________________________
First M.I. Last
Phone: _________________________________________________________________________
Home Cell
Address: _______________________________________________________________________
Street
________________________________________________________________________
City State Zip
Email: ________________________________________________________________________
Emergency Contact Information
Name: _________________________________________________________________________
First M.I. Last
Phone: _________________________________________________________________________
Home Cell
Relationship to Participant: _________________________________________________________
Insurance Provider:______________________________________________________________
Subscriber Name: __________________________ Policy Number: _______________________
Participant Page (Please complete one for each child or infant)
Child’s Name: __________________________________________________________________
First M.I. Last
Preferred Name: _____________________ Date of Birth: ___________________ Grade: _______
month/day/year
Primary Address: ▢ Same as Parent/Guardian 1 ▢ Same as Parent/Guardian 2
School Name (or write nursery): _____________________________________________________
Is your child allergic to any food, medications, materials or insects? Yes ____ No _____
_______________________________________________________________________________
If yes, please list
Does your child have any medical conditions or carry any medication? Yes ____ No _____
_______________________________________________________________________________
If yes, please list
Please describe your child’s strengths and interests: _____________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Please describe your child’s learning style and any special needs: __________________________
_______________________________________________________________________________
What do you hope your child gains by enrolling her/him in this year’s program?: _______________
_______________________________________________________________________________
Please list all persons (other than parent/legal guardian) authorized to pick up your child:
______________________________________________________________________________
Name Relationship to Child
______________________________________________________________________________
Name Relationship to Child
I authorize my child to walk home independently from programming: Yes _____ No _____
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Do you authorize First Congregational Church of Evanston UCC to use photos of your child in church
media (ex. website, Facebook, newsletter)? (Names will not be used) Yes _____ No _____
Parent/Guardian: _________________________________________________________________
Print Signature Date
