UUS:E RE Registration 2016-2017
Child Information
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Grade Level in Fall 2016 *
Gender Identity *
Do we have permission to use this child's image without his or her name in photos and videos pertaining to UUS:E and is programs? *
Are there any allergies or other concerns we should be aware of? This information is confidential. If there are none, please write "none" in the space below. *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Zip Code *
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