4th-5th/6th Grade O.W.L. Sign-up June 26 - 30
For children who will enter 4th-6th grades (or homeschool equivalent) in Fall 2017.

Camp dates: June 26-30, 2017
Camp hours: 9:00 AM – 1 PM; drop-off begins at 8:30 AM
Parent/Caregiver Orientation: June 19, 2017 6:00 PM - 8:00 PM

Fee: No fee is required. You are invited to make a donation to support the program in an amount that you feel aligns with the value of this opportunity for your family and the community.

Child's Information
Child's First and Last Name
Please include both the child's legal and preferred name.
Your answer
Pronoun
Your answer
Are there other identities that you claim that you want to be known/recognized?
Your answer
Grade
What grade will your child enter in Fall 2017?
Your answer
Does your child have any allergies? Any medical or behavioral concerns?
In order to help us meet your child's needs, please list any learning differences, sensitivities, etc.
Your answer
Medical Insurance
Please record your child's health insurance information below. Include company and policy/group number.
Your answer
Parent Information
Parent/Guardian Name(s)
Your answer
Address
Your answer
Email Address(es)
Your answer
Do any other parents share custody of this child?
If yes, please provide their name, phone number, and email.
Your answer
Phone(s)
Your answer
Emergency Contact
In the event a parent cannot be reached, who should we contact? Please provide the Name, Phone Number, and Relationship to the Child.
Your answer
Authorization and Release
By typing my name below as an electronic signature, I hereby grant permission and medical release for my child or ward named above to participate in activities sponsored by the Unitarian Universalist Church of Little Rock (UUCLR). I release UUCLR and all volunteers and employees of UUCLR from any claim I or my child shall have arising out of any sponsored activity of UUCLR. I authorize UUCLR staff and volunteers to provide first aid care or seek emergency medical treatmeat for my child if an injury occurs. I recognize that this permission and release is valid until revoked in writing and delivered to the office of UUCLR.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms