Full name of Student:
(first, middle, last)
Goes by:
Date of birth:
Gender:
Student Email Address:
write none if applicable
Student Phone number:
if none, write 000-000-0000
Allergies:
(write none, if applicable)
Medication/Conditions:
(write none, if applicable)
Grade:
School:
(write home school, if applicable)
School activities involved in (sports, extracurriculars, etc):
Interests:
(singing, drawing, reading, hobbies, etc)
Guardian 1 Name:
[first, middle, (maiden), last]
Guardian 1 Relationship:
Guardian 1 Birthday:
Guardian 1 Phone:
Guardian 1 Email:
Guardian 2 Name:
(write none, if applicable)
Guardian 2 Relationship:
Guardian 2 Birthday:
Guardian 2 Phone:
Guardian 2 Email:
I give Christ Episcopal Church permission to take pictures of my child at youth events and to use those pictures for church publications :