UUCA-CUUPS Minor Registration
(Participating without parent)


Minor's Name:  __________________________   AKA.:  _______________

Parent or Legal Guardian's Name:  _________________________________

Address:  _____________________________________________________

Phone:  ____________________   Alt. Phone(s):  ____________________

E-mail:  _____________________   Member of CUUPS International?  ____

If you will, describe your past and/or current involvement/participation with 

Earth-based spirituality:  _________________________________________

_____________________________________________________________

What are your current interests?  What topics would you like to study and 

what activities would you like to take part in?  _______________________

_____________________________________________________________

What skills and knowledge can you share with the group?  ______________

_____________________________________________________________

Overall, what would you like to get out of being a member of UUCA-CUUPS?

_____________________________________________________________

Consent of Parent/Guardian for Minor to Participate:

I, herewith, give permission for my child, named above, to participate in the activities of the UUCA-CUUPS chapter.  I understand that this unit is an Earth-based spirituality networking group, which conducts proceedings with the safety of all in mind, and do hereby agree to release from liability, indemnify and hold harmless the UUCA-CUUPS chapter and any of its members acting within the scope of federal and state laws for any injury to the minor's person or damage to the minor's property.  I assert that I am the parent or legal guardian of the minor whose name appears above, and by signing below that this release shall be binding upon the minor, the parent(s) or guardian(s), any successors in interest, and/or any person(s) suing on the minor's behalf.

Signed:  ____________________________________   Date:  __________

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Membership Dues Record

________________   $_________          ________________   $_________

________________   $_________          ________________   $_________

________________   $_________          ________________   $_________