Student Information Collection Form

Student Registration Form

Complete One Per Student Per Year
COACH Location*
General Information

Please fill out one per student (per school year)
School Year*
Semester*
Student Name*

First NameMiddle NameLast Name
Student's Preferred Name
Nickname/Name they prefer to be called
Student's Grade Level (for the school year selected)*
Student's Email (create a Gmail email account if he/she does not have an email)*
example@example.com
Student's Phone Number (if he/she has one)
Please enter a valid phone number.
Student's Birth Date*

MonthDayYear
Student's Gender*

Medical Information
Physician Name

First NameLast Name
Physician Primary Phone Number
Please enter a valid phone number.
Physician Secondary Phone Number
Please enter a valid phone number.
Preferred Emergency Hospital Name
Please list any of the followings: current medications, medication allergies, food allergies, or chronic health concerns.

Student Registration Form