St. Andrew's High School & Middle School Youth Group Registration 2016-2017
Student First Name
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Student Last Name
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Date of Birth
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Age
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Grade for the 2016-2017 School Year
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Address
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School
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Student Cell Phone
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Student E-mail
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Parent 1 First Name
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Parent 1 Last Name
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Parent 1 Phone
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Parent 1 E-mail
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Parent 2 First Name
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Parent 2 Last Name
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Parent 2 Phone
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Parent 2 E-mail
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Emergency Contact (other than Parent 1 or 2)
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Emergency Contact Phone
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Preferred Method of Contact for Parent
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Physician
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Physician Phone
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Allergies
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Any medical or behavioral information we should know:
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Any restricted activities? Please explain:
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By checking the box below, I agree to release St. Andrew's Church, St. Andrew's staff, its Church School teachers and youth leaders from any damage or liability resulting from my child's participation in church-sponsored activities for the 2016-17 school year. Further, I give permission for the Church School teachers and/or youth leaders to seek medical care for my child in the event of an emergency.
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Signature (please type)
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Date
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