Shadow Day Request Form

Student Name

First NameLast Name

Age

Gender

Current School

Current Grade

Please indicate whether you are in College Prep, Honors, or another course-level designation:

Please Describe "Other"

Please select your preferred date or dates for your Shadow Day Visit

Parent Name

First NameLast Name

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent Cell Phone

Area CodePhone Number

Parent Email

Where the confirmation will be sent to

Do you know a current ACS student in your grade level who you would like to be your host? If not, ACS will find a perfect match.

If yes, Student Host Name:

First NameLast Name

Emergency Contact. Please list an additional person to contact in case of an emergency.

First NameLast Name

Emergency Contact Phone Number:

Area CodePhone Number

Emergency Contact's Relationship to Student:

Parent/Guardian Permission
In order for your child to attend a Shadow Day Visit at Atlantic Christian School, a parent/guardian must READ and AGREE to all of the following statements. I am the parent/guardian of the child listed above and give permission for my child to attend a Shadow Day Visit at Atlantic Christian School (ACS). I authorize ACS employees to give normal first aid to my child and understand that ACS is not to be held liable for the administration of such health care. I hereby release ACS and all its employees from liability and harm arising to my child during this visit to the school. In the event that I cannot be contacted, I hereby give my permission for any necessary emergency treatment that is administered for the welfare of my child.

Permission

Please verify

SHADOW DAY REGISTRATION FORM