HS Youth Group Permission / Information Form

HS Youth Group Permission / Information Form

Please fill in the form below.
Student's Full Name*

PrefixFirst NameLast Name
Date of Birth
Grade in School
YesNo
Student's Cell Number*

Area CodePhone Number
Cell Service Provider (to send text from email)
YESNO
Parent's Full Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Cell Service Provider (to send text from email)
YESNO
Transportation Permission, blanks (type your name), give permission for my child blank (type student's name) to be picked up from Southern High School on scheduled Friday afternoons and to be transported to Mt. Zion Church (122 Bayard Road, Lothian) for Youth Group. Unless otherwise notified, Mt. Zion is the only destination my child will be transported to. My signature gives consent for this. Signature
YESNO
Photo Release Form (adult signature required)

Clear
Should be Empty: