Sign Up Learning Centers

All participants must register and supply medical info no matter how frequently or infrequently you plan to attend.
Will child attend in 2015-16? (*)
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Will you child attend Learning Centers during the 2015-16 program year? (If you are not sure, check yes.)
Parent 1 Name (*)
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Parent 1 Email (*)
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Parent 1 Phone (*)
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Parent 2 Name (*)
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Parent 2 Email (*)
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Parent 2 Phone (*)
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Street Address (*)
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City (*)
Please enter name of city.
State (*)
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Zip (*)
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Child 1 First Name (*)
Please enter child's full name.
Child 1 Last Name (*)
Please enter child's full name.
Child 1 DOB (*)
Please enter child 1 date of birth.
Include year please.
Child 1 Grade in School, Fall 2015 (*)
Please enter grade, or N/A, PK or PS (3 year olds)
Use NA if not in school
Child 1 Medical
Please enter medical info or N/A if none.
Please list medications or allergies.
Child 2 First Name
Please enter child's full name.
Child 2 Last Name
Please enter child's full name.
Child 2 DOB
Please enter child 1 date of birth.
Include year please.
Child 2 Grade in School, Fall 2015
Please enter grade, or N/A, PK or PS (3 year olds)
Use NA if not in school
Child 2 Medical
Please enter medical info or N/A if none.
Please list medications or allergies.
Child 3 First Name
Please enter child's full name.
Child 3 Last Name
Please enter child's full name.
Child 3 DOB
Please enter child 1 date of birth.
Include year please.
Child 3 Grade in School, Fall 2015
Please enter grade, or N/A, PK or PS (3 year olds)
Use NA if not in school
Child 3 Medical
Please enter medical info or N/A if none.
Please list medications or allergies.
Available to teach? (*)
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We have paid LC teachers but occasionally need subs.

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Union Congregational Church
176 Cooper Avenue
Montclair, NJ 07043
973-744-7424

infoucc@unioncong.org

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