Section 1 - UUPA Local
Contact
New and Annual Renewal
Individuals applying to become or renew your status as a UUPA Local
Contact need to complete the first section only. Groups applying to become a
Local UUPA Chapter or renew their Chapter recognition for another year
must complete both sections, so that the Local Chapter consists of a Local Contact
and two additional Core Members.
Effective October 20, 2001, no fees are charged to become a Local Contact or
Chapter. Annual Chapter renewals are required by UUPA Bylaws.
Please send completed form to:
UUPA
18305 57TH AVE NE
KENMORE WA 98028
Local Contact Application
Name:
__________________________________________
Address: ________________________________________
________________________________________________
________________________________________________ |
Preferred name:
__________________________
Phone: _________________________________
E-mail: _________________________________
UU Congregation: _________________________ |
I agree to be available in the following way(s) (please check all boxes
which apply):
□ WEBSITE:
I give permission for the following to appear on UUPA’s website as
Local Contact information:
|
□ First Name |
□ First
and Last Name |
□ Address listed above |
□ Alternative address: |
|
□ Last
Name |
□
Preferred
Name |
□ City
& State only |
|
|
□ Email
address |
□ Phone
Number |
□ UU
Congregation |
|
|
|
□
|
PUBLICATIONS: I
give permission for the following to appear in UUPA's print publications
as Local Contact information:
|
|
□ First Name |
□ First and Last Name |
□ Address listed above |
□ Alternative address: |
|
□ Last
Name |
□ Preferred
Name |
□ City
& State only |
|
|
□ Email
address |
□ Phone
Number |
□ UU
Congregation |
|
|
|
□ | DO NOT PUBLISH: I do
not wish my information to be published. I agree to contact local people with
inquiries who are referred to me by UUPA.
|
I confirm each of the following (please read and check each box):
□ I am an Active UUPA member OR my individual membership application/renewal form
is enclosed
□ I am a member of the above UU congregation
□ I hereby apply to serve as a UUPA Local Contact
□ If approved by the UUPA Board, I agree to accept referrals from UUPA of persons in
my region seeking information on polyamory and/or Unitarian Universalism and to
contact these persons.
□ I agree to comply with the UUPA bylaws and rules governing local contacts and Local Chapters.
Signature: ____________________________________________________ Date:
________________
|
|
For Chapter Applications or Renewals, proceed to Section 2
Section 2 - UUPA Chapter
New and Annual Renewal
|
□ New Chapter
□ Annual Renewal
|
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The following two persons join
the Local Contact person above in applying to be designated as the Core
Members of a new or renewing Local Chapter of UUPA. |
Second Core Member:
Name:
_____________________________________________
Address:
___________________________________________
___________________________________________________
___________________________________________________ |
Preferred name:
______________________
Phone:
_____________________________
E-mail:
_____________________________
UU Congregation:
____________________ |
I confirm each of the following (please read and check each statement
|
□ |
I am an Active UUPA member OR my individual membership application/renewal form
is enclosed |
|
□ |
I am a member of the above UU congregation |
|
□ |
I hereby apply to be designated by the UUPA Board of Trustees as a Core Member of
a Local Chapter of UUPA |
|
□ |
I agree to comply with the UUPA bylaws and rules governing Local Chapters. |
Signature: __________________________________________ Date:
_______________________________
|
|
Third Core Member:
Name:
_____________________________________________
Address:
___________________________________________
___________________________________________________
___________________________________________________ |
Preferred name:
______________________
Phone:
_____________________________
E-mail:
_____________________________
UU Congregation:
____________________ |
I confirm each of the following (please read and check each statement
|
□ |
I am an Active UUPA member OR my individual membership application/renewal form
is enclosed |
|
□ |
I am a member of the above UU congregation |
|
□ |
I hereby apply to be designated by the UUPA Board of Trustees as a Core Member of
a Local Chapter of UUPA |
|
□ |
I agree to comply with the UUPA bylaws and rules governing Local Chapters. |
Signature: __________________________________________ Date:
_______________________________
|
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Please continue
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Chapter Information:
Name of Chapter:
__________________________________________________________________________
Congregation or Region to be Served (e.g., Shoreline UU Church, Metropolitan
Cleveland, Southern Utah):
_________________________________________________________________________________________
Brief Chapter update
Please include:
* Upcoming activities & plans
* Chapter Meeting Schedule
Renewing chapters include:
* Activities since last update
Attach additional page
if necessary
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______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
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