Connections Program Registration

Fill out the registration form below to enroll your child in our after-school Connections Program.
Please submit one form per child.

Child's Name

First

Last

Name of Parent/Guardian

First

Last

Phone

First parent/guardian's phone number.

Name of Second Parent/Guardian

First

Last

Phone

Second parent/guardian's phone number.

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Child's Date of Birth

Child's Grade in School

Which grade is your child in?

and Message Name

Connections Program Policies

Please read the following document.

Connections Payment Policy and Response to Inappropriate Behavior

I have read and agree with the Connections Payment Policy and Response to Inappropriate Behavior.

Connections Program Dismissal Information

Children will be picked up NO LATER than 5:30 PM. Who is permitted to pick up your child from the Connections Program?

Name and phone of first person other than parent/guardian who may pick up child

First

Last

Name and phone of second person other than parent/guardian who may pick up child

First

Last

Health Information

Please specify any allergies, medications, or other pertinent medical information we should know about for your child.

Emergency Contact(s)

Name

First

Last

Phone

Name

First

Last

Phone

Photo Release

Yes, my child's picture may be used for promotional use only
No, my child's picture may be used for promotional use

I give permission to Panama Global Methodist Church (PGMC) of Panama, New York to use photographs and videos taken of my child participating in the Connections Program of PGMC.

Comments or Message

By checking this box, I confirm I am the parent/guardian, the information is accurate, and I consent to my child’s participation. This serves as my electronic signature.

Contact Us

22 East Main Street
PO Box 218
Panama, NY  14767

Church Office:  (716) 782-4031
Fax: (716) 782-2326
E-mail: adminassist@panamamethodist.org | contact@panamamethodist.org

Office Hours: Mon - Thurs
8:30 am - 4:00 pm

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