First United Presbyterian Church

Name   

Age   

Grade for Fall 
K 1 2 3 4 5 6

Gender 
Male Female

1st UPC Member? 
Member Not a member

(If not a member who invited you) 

Swimming Ability 
Non-swimmer Beginner Advanced

Street Address   

City   

Zip Code   

Home Phone   

Contact Email Address   

Allergies and/or Medical Conditions:

Father Name   

Cell Phone       Work Phone   

Mother Name   

Cell Phone       Work Phone   

Emergency Contact other than parents:

Name       Cell Phone   

Work Phone       Home Phone   

Relationship to child   

Who is picking up (starting with who will be the primary pick up):

Name       Phone   

Name       Phone