Got Lunch Electronic Enrollment

First Congregational Church and Society, United Church of Christ, 6 Payson Hill Rd., Rindge, NH 03461 Mailing address: PO Box 451, Rindge, NH 03461 Phone: 603-899-5722

Copyright 2015 All rights reserved.

Home Phone

Please list any allergies this child may have

2nd Child's Date of Birth

Please list any allergies this child may have

Parent Name: *

If you are not present to accept the delivery, please identify a safe drop off location at your residence where the drivers can leave the groceries.

3rd Child's Date of Birth

Enter color of house or identifying mark for delivery. *

United Church of Christ

6 PAYSON HILL ROAD

RINDGE, NH 03461

603-899-5722

Got Lunch Electronic Enrollment

Street & Town Address *

E-Mail if available

First Congregational Church

Cell Phone

1st Child's Age

If you are enrolling more than 3 children, please submit this form a second time listing your additional children

3rd Child's Name:

Please Note: By submitting this form you agree to release, indemnify and hold harmless the First Congregational Church and Society of Rindge (known as Rindge UCC) and its collaborative partners from all losses, claims, theft, demands, liabilities, causes of action, or expenses, know or unknown, arising out of your participation in the Got Lunch program. You also acknowledge that it is your responsibility to handle the food items properly to prevent spoilage.

1st Child's Name:

Special considerations: Will you be present to receive the groceries? *

I will be present

I will not be present

2nd Child's Age

Please list any allergies this child may have

1st Child's Date of Birth

2nd Child's Name:

3rd Child's Age

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First Congregational Church and Society, United Church of Christ, 6 Payson Hill Rd., Rindge, NH 03461 Mailing address: PO Box 451, Rindge, NH 03461 Phone: 603-899-5722

Copyright 2015 All rights reserved.