Enrollment Form

Family Ministry classes require a UUCB website user name to enroll. If you don’t already have one, use this form to request login credentials.

Do you already have a UUCB website account?*
- Yes
- No
- I don’t know
Parents / Guardians*
A new UUCB website account will be created for each email you provide. Use the “+” icon to add more rows
First Name Last Name
Children*
Use the “+” icon to add more rows.
First Name Last Name Date of Birth
Address*
Where can we deliver class materials?

Street Address City State ZIP Code
Phone
Requested User Name*
What would you like your UUCB website user name to be? Choose carefully, because this can’t be changed later.
Nickname*

What name would you like to use in discussion groups?
Email*

Which email address will you use to access the website?
Are you a UUCB Member?*
- Yes
- No

First Name	Last Name

First Name	Last Name	Date of Birth

Unitarian Universalist Congregation of Binghamton