Student Information Form

Student Information

Name (Nickname too)

This address will receive a confirmation email

Youth Cell

Home Phone

Address

Date of Birth

Parent #1

Parent #1 Name

Address if not the same as the student

Work number

Cell number

This address will receive a confirmation email

Adult #2 (or next Emergency contact)

Adult #2 name

Work Phone

Cell Phone

Address if not the same as the student

Adult #3 (or next Emergency contact)

Adult #3 Name

Phone

Address if not the same as the student

Parent #4 (or next Emergency contact)

Adult #4 Name

Phone

Address if not the same as the student

Emergency Contacts

List in order of preferred contact and any additional people to contact if those ahead are not available (recommend 4+ contacts)

Emergency Information

Community Agreement

Date Acknowledged

Type full name if agree

Description

This form will email the student ministries director to support communication and any emergencies when your student is with us.