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

Submit

Never submit passwords through Google Forms.

This form was created inside of Richmond Chinese Alliance Church. Report Abuse - Terms of Service

Forms