STUDENT INFORMATION SHEET: RCAC English Youth and Young Adult Ministries
Please complete the form below regarding Youth and Young Adult Information. All information will remain confidential.
STUDENT INFORMATION:
Student Full Name: *
Student Phone Number: *
Student Email Address: *
Student Birthday: *
What school do you attend? *
What grade are you in? *
STUDENT MEDICAL INFORMATION:
Student BC CareCard Number: *
Family Doctor Name: *
Family Doctor Phone Number: *
Please list any allergies and dietary restrictions:
Does the student have any physical, emotional, mental or behavioural needs that RCAC staff and volunteers should be aware of?
PARENT/GUARDIAN INFORMATION:
Please complete information regarding the contact information of Parent/Guardian(s) of the student. List multiple names if needed.
Main Parent/Guardian Contact: *
(1) Relationship with Student: *
(1) Parent/Guardian Phone Number (this is the number that information will be sent to): *
(1) Parent/Guardian Email Address (this is the email information will be sent to): *
Secondary Parent/Guardian Contact:
(11) Relationship with Student:
(11) Parent/Guardian Phone Number:
EMERGENCY CONTACT INFORMATION:
In case of emergency, please list the contact information of a caregiver.
Emergency Contact Name (Different from Main and Secondary Parent/Guardian Contact): *
Relationship with student:
Emergency Contact Phone Number: *
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