Parent-Provided Information for Student Dietary/Medical Needs

Parent-Provided Information for Student Dietary/Medical Needs
Dear Parent,

Help us better serve your child by completing this form. You will have an oppurtunity to note any dietary concerns, medical needs, etc. You may also include any specific emotional or behavioral concerns that you would like our staff to be aware of. All information is voluntary but dietary concerns are required for meal preperation and planning. We will also work with your church leaders to ensure we are equipped to work with, serve and care for your child while they are with us at JP.
Dates attending the Jeremiah Project:*
Parent's Name

First Name Last Name
Name of Child*

First Name Last Name
Email*
Address*

Street Address

Street Address Line 2

City State

Zip Code
Church Name*
Spelled out completely (no abbreviations)
What grade will your child have completed in June 2023?*

5th grade6th grade7th grade8th grade9th grade10th grade11th grade12th grade
Male or Female*

MaleFemale
Please list any Dietary Concerns such as: food allergies, food intolerances, celiac disease, vegetarian etc.
Please note any medical, emotional or behavorial concerns you may wish for our staff to be aware of:
Should be Empty: