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: *
Your answer
Student Phone Number: *
Your answer
Student Email Address: *
Your answer
Student Birthday: *
Your answer
STUDENT MEDICAL INFORMATION:
Student BC CareCard Number: *
Your answer
Family Doctor Name: *
Your answer
Family Doctor Phone Number: *
Your answer
Please list any allergies and dietary restrictions:
Your answer
Does the student have any physical, emotional, mental or behavioural concerns that RCAC staff and volunteers should be aware of? Please explain.
Your answer
PARENT/GUARDIAN INFORMATION:
Please complete information regarding the contact information of Parent/Guardian(s) of the student. List multiple names if needed.
(1) Parent/Guardian Full Name: *
Your answer
(1) Relationship with Student: *
Your answer
(1) Parent/Guardian Phone Number (this is the number that information will be sent to): *
Your answer
(1) Parent/Guardian Email Address (this is the email information will be sent to): *
Your answer
(11) Parent/Guardian Full Name:
Your answer
(11) Relationship with Student:
Your answer
(11) Parent/Guardian Phone Number:
Your answer
EMERGENCY CONTACT INFORMATION:
In case of emergency, please list contact information of caregiver.
Emergency Contact Name: *
Your answer
Relationship with student:
Your answer
Emergency Contact Phone Number: *
Your answer
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