UUPA Local Contact & Chapter Application
Revised August 2006    pdf

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  DO NOT PUBLISH: I do not wish my information to be published.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

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: _______________________________

Please continue

 

 

 

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

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
_______________________________________________________________

Thank you!