2017 Canvas - Week 2 Registration (July 10-14)

Please complete one registration for each child.

Please know the curriculum and activities for each Canvas week will be the same. You are welcome to sign up for one week or both weeks.

COST: $75 per child.


Child's First Name*:

Child's Last Name*:

Gender*:

Birthdate mm/dd/yyyy*:

Age (on the first day of camp)*:

Grade entering*:

t-shirt size:


Food or Medical Allergies:
leave blank if none

Medical Concerns:
leave blank if none


Parent/Guardian Information

Parent/Guardian First Name*:

Parent/Guardian Last Name*:

Cell Phone (###-###-####)*:
select primary cell

Cell Phone (###-###-####)*:
select secondary cell

Home Phone (###-###-####):

Parent/Guardian Email*:

Address*:

City*:

State*:

Zip*:


Emergency Contact Information

Emergency Contact Name*:

Relationship*:

Phone (###-###-####)*:


*PHOTO/VIDEO RELEASE
For privacy and safety, we will not publish names with photographs/videos.
I authorize the use/release of photographs and/or videos that include the INDIVIDUALS NAMED ABOVE for UCUMC use, in print and electronic materials (worship videos, e-mail blasts, church website, Facebook, etc.).

Photo/Video Release Given
Photo/Video Release Denied


*RELEASE: Submitting this on-line form will be the equivalent of signing a paper registration form.
Yes, I agree

Name of Adult filling out this form*:

Date Electronically Signed mm/dd/yyyy*:

Payment via*: Online Check
Due upon registration.

Person making payment (if other than parent):
 



 
Please enter the text from the image in the box