2013-2014 The UU Church of Rockford: CHURCH SCHOOL REGISTRATION FORM
*Church school runs from September thru May. Summer Fun Activities Memorial Day through Labor Day.
Please fill out this form before attending our church school, paper forms are also available at church.
Questions or Concerns, please contact KImberlee Carlson (815) 398-6322 pd@uurockford.org
Student Information
Please include information for each of your children participating in our church school program or in nursery care.
Student 1 First Name *
Your answer
Student 1 Last Name *
Your answer
Student 1 Birthdate *
Please use format of month/date/year (12/11/10)
Your answer
What grade is your child (Student 1) in at school this year/home school equivalent?
Student 2 First Name
Your answer
Student 2 Last Name
Your answer
Student 2 Birthdate
Please use format of month/date/year (12/11/10)
Your answer
What grade is your child/ Student 2 in at school this year/home school equivalent?
Student 3 First Name
Your answer
Student 3 Last Name
Your answer
Student 3 Birthdate
Please use format of month/date/year (12/11/10)
Your answer
What grade is your child/ Student 3 in at school this year/home school equivalent?
Student 4 First Name
Your answer
Student 4 Last Name
Your answer
Student 4 Birthdate
Please use format of month/date/year (12/11/10)
Your answer
What grade is your child/ Student 4 in at school this year/home school equivalent?
Student 5 First Name
Your answer
Student 5 Last Name
Your answer
Student 5 Birthdate
Please use format of month/date/year (12/11/10)
Your answer
What grade is your child/ Student 5 in at school this year/home school equivalent?
Parent Information
First and last Name of Adult Responsible #1 *
Your answer
Primary Phone of adult responsible #1 *
Your answer
E-mail Address of Adult responsible (#1) *
Your answer
First and last Name of Adult Responsible #2
Your answer
Primary Phone of adult responsible #2
Your answer
E-mail Address of Adult responsible (#2)
Your answer
Mailing Address *
Street Address, City, Zip
Your answer
Does any student registered above have any allergies and/or special needs we should know about?
If yes, identify the student and explain:
Your answer
Please indicate “special needs,” or other information that would be helpful to the teachers.
Your answer
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