Student United Weekend
January 23-24
Name
*
First Name
Last Name
Gender
Male
Female
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Parent/Guardian Email
*
example@example.com
Does the student have any medical concerns we should be aware of?
Please list any allergies the student has:
Please list any medication the student will need to take:
Please list 2 Emergency Contacts for the student and include name, number, and relation to student:
Student Phone Number
Please enter a valid phone number.
Current Grade?
*
T-shirt Size?
*
Please sign to show you understand that your student might have their picture taken for social media and promo purposes within Bethel.
Submit
Should be Empty: