2019-2020 Student Registration
Email address *
First Name of Student *
Your answer
Last Name of Student *
Your answer
Gender *
Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Grade (beginning in August 2019) *
Name of Parent/Guardian(s) *
Your answer
Parent/Guardian(s) Cell Phone Number (Please specify which parent) *
Your answer
Emergency Contact Name and Number *
Your answer
Student Cell Phone Number
Your answer
Allergies (Write N/A if none) *
Your answer
List Any Special Needs, Medications, and/or Medical Concerns for Child (Write N/A if none) *
Your answer
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
Your answer
Has Student Been Immersed?
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. *
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Name of Person Signing *
Your answer
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