Parent / Guardian Information

Father's First Name Father's Last Name

Street Address City State Zip

Home Phone (XXX-XXX-XXXX) Work/Cell Phone (XXX-XXX-XXXX)

Mother's First Name Mother's Last Name

Street Address City State Zip

Home Phone (XXX-XXX-XXXX) Cell Phone (XXX-XXX-XXXX)

Would you like to receive Youth's Ministry updates by email? Yes No

Family email Student lives with Both Parents Mom Dad Grandparents Guardian Other

Emergency Contact (If both parents are unavailable)

Name * Relationship to youth*

Home Phone (XXX-XXX-XXXX) Cell Phone (XXX-XXX-XXXX)

Individual Student Information (Youth 5th - 12th Grade)

1.) Student's Name* Date of Birth* (XX-XX-XXXX)

Baptismal Date (XX-XX-XXXX) Church Confirmed in:

Grade School Student's Email

List any chronic condition/illness: (if None, Please state) *

List any allergies and severity of reations: (if None, Please state) *

Anything else your Leader should know

2.) Student's Name Date of Birth (XX-XX-XXXX)

Baptismal Date (XX-XX-XXXX) Church Confirmed in:

Grade School Student's Email

List any chronic condition/illness: (if None, Please state)

List any allergies and severity of reations: (if None, Please state)

Anything else your Leader should know

3.) Student's Name Date of Birth (XX-XX-XXXX)

Baptismal Date (XX-XX-XXXX) Church Confirmed in:

Grade School Student's Email

List any chronic condition/illness: (if None, Please state)

List any allergies and severity of reations: (if None, Please state)

Anything else your Leader should know

4.) Student's Name Date of Birth (XX-XX-XXXX)

Baptismal Date (XX-XX-XXXX) Church Confirmed in:

Grade School Student's Email

List any chronic condition/illness: (if None, Please state)

List any allergies and severity of reations: (if None, Please state)

Anything else your Leader should know