Registration Form

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UCCVA offers a variety of activities throughout the week for kids, teens, and adults.

Based on your interests, you can join various classes and clubs at UCCVA. The duration of the classes are 1 hour long.

Student 1 First Name *

Student 1 Last Name *

Student 1 Age *

Student 1 Gender *FemaleMale

Student 2 First Name

Student 2 Last Name

Student 2 Age

Student 2 GenderFemaleMale

Student 3 First Name

Student 3 Last Name

Student 3 Age

Student 3 GenderFemaleMale

Student 4 First Name

Student 4 Last Name

Student 4 Age

Student 4 GenderFemaleMale

Which club are you registering for? *

Emergency Contact Full Name *

Emergency Contact Phone # *

Relation to Child *

Email Address *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Does your child(ren) have any disability, illness or allergy of any kind, which may require special attention or would limit participation in class activities? *YESNO

If YES, describe breifly:

Media Consent *

I understand and give permission for photographs and videos of named persons and/or participants and/or myself to be used in print or broadcast media as deemed appropriate for the promotion of UCCVA.

Absence When Sick *

I understand that if my child(ren) has visible signs of sickness like: fever, sneezing, constant coughing, stomach flu, I will not bring my child(ren) to practice.

If we find that your child does not feel well, we will separate your child from others and call you to pick up the child as early as possible.