Legacy Student Ministry Registration Form

2020-2021 Legacy Student Registration Form

PLEASE COMPLETE A SEPARATE FORM FOR EACH STUDENT REGISTERED.
Student's Name *

First Name Last Name
Primary Parent Contact's Name *

First Name Last Name
Primary Parent Email Address *
Student's Email Address
example@example.com
Primary Contact Phone Number *

Area Code Phone Number
Student's Contact Phone Number

Area Code Phone Number
1. Additional Adult Authorized to Pick Up your Child

First Name Last Name
2. Additional Adult Authorized to Pick Up your Child

First Name Last Name
3. Additional Adult Authorized to Pick Up your Child

First Name Last Name
Secondary Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Student's Date of Birth *

Month Day Year
Any Allergies?
Student's Grade in School *
Do we have permission to post pictures of your teenager on Social Media?

Yes No
I understand that other physical forms need to be filled out for other youth activities *

Yes, I understand
Any special needs or concerns you would like to share regarding your teenager?
Should be Empty:

2020-2021 Legacy Student Registration Form