This form will be required for all children and youth who will be attending UUCR's Faith Formation classes and outings during the 2019-2020 church year. Total number of parents/guardians * - Select -123 Total number of children/youth * - Select -1234 First Child/Youth Information: First Name * Last Name * Nickname Birthdate * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2001200220032004200520062007200820092010201120122013201420152016201720182019202020212022 School Grade as of September 2019 * - Select -Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade Doctor's Name Doctors Number Insurance Carrier Insurance information is most necessary for middle and high school students who may participate in overnights and/or off-campus community service or fun events during this church year. Insurance Card Holder Name of adult who is the main carrier of the insurance coverage. Insurance Policy or ID Number Policy Number (or ID Number) Ins Phone Hobbies and Interests of Child Dietary Preferences - None -Ovo-vegetarian (diet includes eggs but not dairy products)Lacto-vegetarian (diet includes dairy products but not eggs)Ovo-lacto vegetarian (diet includes both eggs and dairy products)Vegan, or strict vegetarian (diet excludes all animal products: eggs, dairy, honey, etc.)Pescetarian (diet has been described as "fish but no other meat")Pollo-pescetarian, which includes poultry and fish, or "white meat" only Allergies Milk Eggs Seafood and Shellfish Peanuts and tree nuts Soy Wheat Insect Stings Other Allergy Please check all that apply ADHD Asperger's Syndrome Autism Behavior diagnosis Diabetic Down's Syndrome Epilepsy Hard of hearing Hyperactive Low vision Sensory Issues Uses a wheelchair Other Diagnosis If you responded to the last two questions, what are the best communication and teaching styles for your child? Conference with DRE Yes, please No thank you Would you like the Director of Religious Education to contact you for a conversation regarding your child's needs? Publicity Consent - Photographs * Yes No Images, including individual and group photographs will not be used in publications created by/for UUCR without the permission of the parent/guardian. This pertains to images used on the uucr.org website, email correspondence, congregational brochures/posters and on bulletin boards located in the church buildings. Answering "Yes" means you grant permission for photos of your child taken during UUCR events/activities to be published on the church website, church-only emails, and congregational brochures/posters or in the church building. No names will be attached. Printer-friendly version
