St. Andrew's High School & Middle School Youth Group Registration 2017-2018
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 2017-2018 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 *
Your answer
Parent 1 E-mail *
Your answer
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
Your answer
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 *
Required
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 2017-2018 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. *
Required
Signature (please type) *
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Date *
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