YOUTH ENRICHMENT PROGRAM REGISTRATION FORM
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Email *
STUDENT INFORMATION
 First and Last Name *
Youth Education Programs *
Required
PARENT'S/GUARDIAN'S INFORMATION:
First and Last Name *
 E-mail address *
Phone Number (Home/Cell) *
Home Address *
City, State, Zip *
YEP MEDICAL INFORMATION:
Any allergies, illnesses or other concerns? *
Are there any restrictions to play or activities? *
PHOTOGRAPHY/VIDEOTAPING PERMISSION:
I grant Unity Church of Christianity Valley Stream the right to take photos/videos of my child. I agree that Unity Church of Christianity Valley Stream may use such photographs/videos for such purposes as publicity, illustration, advertising, and Web Content.  I have read, understand and agree to the above.
Signature (please type) *
EMERGENCY CONTACT:
In the event of an emergency and you are not reachable, who should we contact?
Name and Relationship to Child: *
Contact Phone #: *
Name and Relationship to Child: *
Contact Phone #: *
AGREEMENT:
By checking the box below, you agree that all information is correct, and your typed signature  acknowledges your request to accept your child in the YEP program. *
Required
PARENT'S/GUARDIAN'S SIGNATURE:
Signature: *
Date: *
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YYYY
A copy of your responses will be emailed to the address you provided.
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