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