Confirmation Registration Form

High School Registration Form
Student Information
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*
School
Incoming Grade*
Student's Cell Number*
Please enter a valid phone number.
Has student been baptized?

YesNo
If yes, approximate date:

Parent/Guardian Information
Parent/Guadian 1:

First NameLast Name
Is parent a member of Servant of Christ?

YESNO
If no, please indicate where church membership is held, if any:
Primary Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:
Please enter a valid phone number.
Email
example@example.com
Parent/Guardian 2:

First NameLast Name
Is parent a member of Servant of Christ?

YESNO
If no, please indicate where church membership is held, if any:
Parent/Guardian Address 2 (if different than above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com

Emergency Contact Information

In case parents cannot be contacted, please list an alternative contact. Parents will always be contacted first.
Emergency Contact | Contact Name

First NameLast Name
Emergency Contact | Phone Number
Please enter a valid phone number.
Relation to Student?

Medical Information

Insurance Information in Case of Emergency (if parent's cannot be reached)
Medical Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy/Group #
Insurance Phone Number
Please enter a valid phone number.
Please list any of the following: current medications, medication allergies, physical restrictions, differently abled, food allergies, or chronic health concerns.

Enrollment Policy:

By submitting this form, I agree that my child and I have read and understand the expectations laid out below and in the Confirmation Parent Handbook (found online).
*As this student's parent/legal guardian, I grant permission for him/her to participate fully in the High School Program, related trips (service projects, etc.), and activities of Servant of Christ. If I cannot be reached in an emergency, I give permission to the supervising staff and/or leaders of Servant of Christ to sign forms that would ensure my child's necessary and immediate treatment. I give permission to those administering emergency treatment to do so, using those measures deemed necessary. I understand that neither Servant of Christ nor those acting on behalf of Servant of Christ will be held liable in case of accident or injury as long as there is no gross negligence.
*I give permission for this student to leave the premises of Servant of Christ ONLY for discipleship and fellowship events through SOC High School Programming, either in a vehicle of an adult guide or in the church bus. I grant Servant of Christ permission to use photos of my child without compensation or prior notification. I also understand that my child cannot use alcohol, tobacco, drugs, or weapons of any kind, or participate in inappropriate sexual activity or potentially harmful behavior. If these rules are broken, I will assume the transportation costs to return my child home immediately by the safest means.
I give Servant of Christ permission to utilize any photos of my student while attending Servant of Christ events in any social media posts or advertising.
Dated

MonthDayYear
Date
Should be Empty:

High School Registration Form

Student Information

Parent/Guardian Information

Emergency Contact Information

Medical Information

Enrollment Policy: