2019-2020 UUCSR RE Registration
Parent/Guardian #1 Name *
Your answer
Parent/Guardian #1 Primary Phone Number *
Your answer
Parent/Guardian #1 Email Address *
Your answer
Parent/Guardian #2 Name (optional)
Your answer
Parent/Guardian #2 Primary Phone Number
Your answer
Parent/Guardian #2 Email address
Your answer
Child #1 Name *
Your answer
Child #1 Preferred Pronouns *
Your answer
Child #1 Birth Date *
MM
/
DD
/
YYYY
Child #1 Grade in September 2019 *
Child #2 Name
Your answer
Child #2 Preferred Pronouns
Your answer
Child #2 Birth Date
MM
/
DD
/
YYYY
Child #2 Grade in September 2019
Child #3 Name
Your answer
Child #3 Preferred Pronouns
Your answer
Child #3 Birth Date
MM
/
DD
/
YYYY
Child #3 Grade in September 2018
Child #4 Name
Your answer
Child #4 Preferred Pronouns
Your answer
Child #4 Birth Date
MM
/
DD
/
YYYY
Child #4 Grade in September 2019
Emergency Alternate Contact *
Your answer
Emergency Alternative Contact Phone *
Your answer
Child's Physician *
Your answer
Physician's Phone *
Your answer
Health Insurance Provider *
Your answer
Allergies
Do any of your children have any allergies? If so, please indicate the name of the child, the allergen, the type of reaction, and specified care for said reaction.
Your answer
Special Needs
Do any of your children have special needs or conditions that we should know about (e.g. health issues, medical conditions, learning disabilities, special needs, dietary restrictions, medications; family circumstances such as a divorce, death, move or new school)? May we communicate those to his/her RE teachers?
Your answer
Consent and Agreement *
Should any emergency arise, I grant permission for my child to receive treatment from an appropriate health care provider to be selected by the responsible adult supervisor, when, in such supervisor's opinion, the need for such treatment is immediate, and when efforts to contact me (parent/guardian) are unsuccessful. I also agree to pay and be responsible for all medical, hospital and other expenses which UUCSR and/or any and all adult supervisors may incur as a result of securing such treatment.
Photography/Video Permission and Publication (check any or all boxes to give consent)
Volunteering at UUCSR
Our Religious Education program runs only if we have enough volunteers to dedicate their time and energy to the program, but there are many ways to help. We ask that each household volunteer at some point throughout the year as a way of giving back for the many things UUCSR offers our families.
Please select one or more options from the following menu about areas you would be willing to volunteer. The RE Committee or a staff person will be in touch with you.(Note: If you or a family member are already volunteering in an area, just check the box where you already help out.) *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service