Shadow Day Request Form

Student Name*

First NameLast Name

Age*

MaleFemale

Current School*

Current Grade*

College PrepHonorsOther

Please Describe "Other"

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

YesNo

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.

Yes, I have read and agree

Please verify*

SHADOW DAY REGISTRATION FORM