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.
* Required
STUDENT INFORMATION:
Student Full Name:
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Your answer
Student Phone Number:
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Your answer
Student Email Address:
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Your answer
Student Birthday:
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Your answer
What school do you attend?
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Your answer
What grade are you in?
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Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Post-secondary
Other
STUDENT MEDICAL INFORMATION:
Student BC CareCard Number:
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Your answer
Family Doctor Name:
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Your answer
Family Doctor Phone Number:
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Your answer
Please list any allergies and dietary restrictions:
Your answer
Does the student have any physical, emotional, mental or behavioural needs that RCAC staff and volunteers should be aware of?
Your answer
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:
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Your answer
(1) Relationship with Student:
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Your answer
(1) Parent/Guardian Phone Number (this is the number that information will be sent to):
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Your answer
(1) Parent/Guardian Email Address (this is the email information will be sent to):
*
Your answer
Secondary Parent/Guardian Contact:
Your answer
(11) Relationship with Student:
Your answer
(11) Parent/Guardian Phone Number:
Your answer
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):
*
Your answer
Relationship with student:
Your answer
Emergency Contact Phone Number:
*
Your answer
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