9th - 12th Grade Student Information & Permission

Student Information:

Student 1

With whom does this child primarily live?

STUDENT'S Cell Phone Number

Area CodePhone Number

Receive texts?

STUDENT'S Email

example@example.com

Gender identity:

Student's Birth Date

Grade

School

Important Information about Student:

(Health, Physical, Learning, Emotional, Family Arrangements, Prescription Needs, MEDICINE, FOOD or OTHER ALLERGIES or Other Concerns/Limitations)

Student 2

With whom does this child primarily live?

STUDENT'S Cell Phone Number

Area CodePhone Number

Receive texts?

STUDENT'S Email

example@example.com

Gender identity:

Student's Birth Date

Grade

School

Important Information about Student:

(Health, Physical, Learning, Emotional, Family Arrangements, Prescription Needs, MEDICINE, FOOD or OTHER ALLERGIES or Other Concerns/Limitations)

Student 3

With whom does this child primarily live?

STUDENT'S Cell Phone Number

Area CodePhone Number

Receive texts?

STUDENT'S Email

example@example.com

Gender identity:

Student's Birth Date

Grade

School

Important Information about Student:

(Health, Physical, Learning, Emotional, Family Arrangements, Prescription Needs, MEDICINE, FOOD or OTHER ALLERGIES or Other Concerns/Limitations)

Home Church (if not St. John's)

PERMISSION FOR TRANSPORTATION: On occasion St. John's may have off-site activities planned. I give permission for my child to ride in a vehicle driven by an adult leader or volunteer. All riders are required to wear a seatbelt.

Parent/Guardian Electronic Signature

First/Last name

Parent(s)/Guardian Contact Information:

Our partnership with you to enhance your child's faith journey is very important. We want you to be informed so that you can support and encourage your child's participation. We hope for your active involvement as well. Our primary communication tool is email, so please provide us with an email address that you check regularly.

Parent/Guardian's Name

Partner's Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number

Area CodePhone Number

Receive texts?

Home Phone Number (land line)

Area CodePhone Number

Preferred Email Address

example@example.com

Parent/Guardian's Name

Partner's Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number

Area CodePhone Number

Receive texts?

Home Phone Number (land line)

Area CodePhone Number

Preferred Email Address

example@example.com

Please provide any additional information needed to help us better communicate with you and those involved in your child's faith journey.

Additional/ Emergency Contact (Other than Parent)

Name

Phone Number

Area CodePhone Number

Relationship

Include in group emails?

Preferred Email Address

example@example.com

MEDICAL RELEASE: I give my permission for the St. John’s leaders to administer basic first aid to my child in the event of an injury. I understand that the St. John’s leaders will contact emergency services in the event of a significant injury and all expenses for such emergency services will be paid by me. (Please provide a copy of your health insurance card.)

PHOTO RELEASE

I agree that by submitting this form, I am submitting my electronic signature.

Parent/Guardian Signature

9th-12th Grade Student Information & Permission