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Emerson Unitarian Universalist Church

Religious Education for Children & Youth Program Registration

For safety and administrative reasons, the Religious Education Committee asks that you complete this registration form. Only one form is needed per family. Please complete and submit online. If you prefer to print, download it from the Children/Youth section of the emerson website and bring it to the RE Office or mail your completed form to: Katy Carpman, Director of Religious Education, Emerson UU Church, 1900 Bering Dr., Houston, TX 77057

Date *
MM / DD / YYYY
Parent/Guardian #1: *
First Last
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone (H) *
### - ### - ####
Phone (W)
### - ### - ####
Phone (Cell)
### - ### - ####
Email *
Parent/Guardian #2:
First Last
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone (H)
### - ### - ####
Phone (W)
### - ### - ####
Phone (Cell)
### - ### - ####
Email
Child(ren) live with:
Please select one above or type in the name below.
Child(ren) live with: Other
Child #1
Name of Child
First Last
Birth Date
Ex. 07151982
Age
Grade as of 9/9
District or Private School
Child #2
Name of Child
First Last
Birth Date
Ex. 07151982
Age
Grade as of 9/9
District or Private School
Child #3
Name of Child
First Last
Birth Date
Ex. 07151982
Age
Grade as of 9/9
District or Private School
Additional Information
In the box above please add additional child information and/or indicate any personal concerns you want the DRE to know about, i.e. allergies, developmental issues, etc.
Photo Permission
Yes
No
Please check YES box if you give the Religious Education Program permission to use your child(ren's) photographs in various publications created by and for the Emerson Unitarian Curch. Please Note: We will never include names of children with photos.

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Child #1

Child #2

Child #3