2020-2021 Student Registration
Email address *
First Name of Student *
Last Name of Student *
Gender *
Address *
City *
Zip Code *
Date of Birth *
MM
/
DD
/
YYYY
Grade (beginning in August 2020) *
Name of Parent/Guardian(s) *
Parent/Guardian(s) Cell Phone Number (Please specify which parent) *
Emergency Contact Name and Number *
Student Cell Phone Number
Allergies (Write N/A if none) *
List Any Special Needs, Medications, and/or Medical Concerns for Child (Write N/A if none) *
Does Your Child Need Transportation? *
Berlin Christian Church Has Permission to Transport Child *
Please List Other People Who Have Permission to Transport and Check-Out Child
Has Student Been Immersed?
Clear selection
Berlin Christian Church Has Permission to Photograph Child *
This Form Was Filled Out For (choose all that may apply) *
Required
By entering your name in the box below, you are indicating that you are 18 years or older, and that all the information on this form is true and accurate, to the best of your knowledge. *
Required
Name of Person Signing *
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