Peace UCC Faith Formation Enrollment 21-22

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Do you have a child or teen in Peace UCC's programming? Use this form to ensure we have all the important information needed in case of emergency.

Families with multiple children/teens: You only need to fill out ONE form and list all your children's names.

Thank you for helping us plan for this year and to keep our information current!

Email *

Contact Information

Home Address

Parent/Guardian Name 1

Parent/Guardian Cell Phone 1

Parent/Guardian Preferred Email 1

Parent/Guardian Name 2

Parent/Guardian Cell Phone 2

Parent/Guardian Preferred Email 2

Do you want to receive text messages?

Yes

Clear selection

Child(ren)/Teen Name/ Preferred Pronoun/Date of Birth/ Grade/ School. Preschool must be 3 by 9/11/2022

Example: Sarah/ Her/ March 6 2011/ 2nd grade/ Jefferson

Authorized pick up and emergency contacts other than those listed above (Name/Relationship/Contact Info; include child/teen names as necessary)

Allergies (Food and Environment), Chronic Illness or Medical Concerns (please identify with child/teen's name first to keep information separate)

Other Important information that should be shared (please identify with child's/teen's name first to keep information separate).

Custody, Physical Behavior, or Developmental Information (will be kept confidential; identify with child/teen's name first)

Anything else you would like us to know?

Medical Permission:

By clicking here, I give permission for my child/teen to participate in activities sponsored by Peace UCC.

In case of emergency, the adult in charge has authorization to seek any medical attention deemed necessary.

My child has permission to receive over the counter medication from the adult in charge.

Photo Permission:

By clicking here, I give permission for Peace UCC to use photographs of my child/teen in any official, educational or publicity pieces. These include, but are not limited to, new releases, publications, PowerPoint, video, website, Facebook, Instagram, or other media.

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THIS SECTION IS ADDITIONAL FOR TEENS IN GRADES 6-12 ONLY

Teen Cell Phone (if more than 1 teen, please specify with name first)

Receive Texts?

Yes

Clear selection

Teen Email (if more than one teen, please specify with teen name first)

Thank you!

Submit

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