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Please return this form directly to the church office. No child may participate in the church's education program without having first been registered. 1. NAME_______________________________________________ AGE_____ DATE OF BIRTH____________GRADE IN AUGUST_____ 2. NAME_______________________________________________ AGE_____DATE OF BIRTH__________ GRADE IN AUGUST___ ADDRESS____________________________________________________ ______________________________________________ZIP__________ PLEASE INDICATE ANY ALLERGIES OR ANY SPECIAL PHYSICAL OR DIETARY NEEDS ____________________________________________________________ _____________________________________________________________ _______________________________________ Parent/ Guardian/Responsible adult______________________________ _____________________________________________________________ Address (if different from above)_______________________________ ________________________________________________ Telephone___________________ Second telephone in case of emergency____________________ Email______________________________________________
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All rights reserved. Reproduction in whole or in part in any form or medium without express written permission of UUCFM is prohibited. |