2016-2017 RELIGIOUS EDUCATION REGISTRATION FORM  
People’s Church Unitarian Universalist  
This form must be on file in DRE’s Office for your child/ren to participate in our programs

          Parent#1 or Guardian Information			            Parent #2 or Guardian Information

Name(First/last) ________________________________	Name(First/last) ___________________________________
_____________________________________________	____________________________________________			Address 						Address 	
____________________________   ______________	 ___________________________    _______________		City			            Zip			                    City			      Zip		 (____)_______________     (____)_________________    	(_____)_____________  (____)____________________
Phone (cell/home) 		Phone (work)                                 Phone (cell/home)		       Phone (work)                      
___________________________________________              ____________________________________________
Email						               Email	
___________________________________________             ____________________________________________
Youth’s Email						 Youth’s Email	
I would like to receive the monthly church E newsletter        Y        N	

CIRCLE:     MEMBER?    FRIEND?    VIISTOR?   How did you hear about us? ______________________________________
Please list all children nursery through high school who will attend our programs 
Child’s Name (first & last)		          Birth date	      Age 	    Grade 	    List Allergies / Concerns?
1.	_______________________________________________________________________________________________
2.	_______________________________________________________________________________________________
3.	_______________________________________________________________________________________________
4.	_______________________________________________________________________________________________

Field Trip Permission  
My child/ren named on this form has permission to participate in short field trips during regularly scheduled religious education classes (walks, visits to other churches, etc.).  Church-sponsored youth activities outside of Sunday and Wednesday on-site RE time use separate permission slips.
Please indicate:      YES____________               NO____________

Medical Release
I hereby, as parent or guardian of the minor child/ren named on this form give permission to the Religious Education program staff or volunteers of Peoples Church Unitarian Universalist of Cedar Rapids, IA in the case of medical emergency to give first aid and/or take my child/ren to the nearest medical facility or to:

Hospital Preference___________________________________________________________________________________	

Physician_________________________________________________________Telephone (_____) ___________________

I also give the physician and/or hospital permission for any and all procedures necessary for the treatment of my child/ren.

Parent/Guardian Signature___________________________________________	Date________________________

Permission to Photograph/Videotape
I grant permission to RE program staff or volunteers of Peoples Church Unitarian Universalist to photograph or videotape my children during the normal course of religious education programs for use in promotional materials.

Please indicate:      YES____________               NO____________
Thank You!
* Please contact the minister directly to discuss options if this would present a barrier to your family becoming a part of this welcoming community.