K-8th Student Information Form 2026-27
Please fill out this form and click submit.
Ministries student will be involved in:
*
Please select all that apply.
Gems
Cadets
Sunday School
Student's Name
*
Birth date
*
Gender
*
Please select one option.
Male
Female
Select Option
Male
Female
Grade
*
Please select one option.
1
2
3
4
5
6
7
8
9
10
11
12
Select Option
1
2
3
4
5
6
7
8
9
10
11
12
Address
*
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Student's Phone
Student's Email
Parent/Legal Guardian Information
Parent/Guardian Name
*
Home Phone
Cell Phone
Parent/Guardian Email
*
This address will receive a confirmation email
Emergency Contact if Parent/Guardian cannot be reached
*
Emergency Contact Phone
*
Helpful Information
Student Allergies and Health Concerns:
Other information regarding your student that would be helpful for counselors/teachers:
Names of any siblings attending:
Insurance Information
Physician
Office Phone
Insurance Carrier
Insurance Policy Number
Waiver
As the parent/legal guardian of this child, I give permission for him/her to participate in any activities pertaining to the Children's/Youth ministries at Harlem Reformed Church.
*
Please select all that apply.
I agree
As the parent/legal guardian of this child, I release Harlem Reformed Church, their staff and volunteers from any liabilities that could result from unintentional accidents and/or self inflicted harm.
*
Please select all that apply.
I agree
As the parent/legal guardian of this child, I give permission for the use of photographs in which they are included for church publicity.
*
Please select one option.
I agree
I disagree
As the parent/legal guardian of this child, I give permission for him/her to be driven to and from organized youth events (including, but not limited to: retreats, mission trips, other outings) by designated persons over the age of 21.
*
Please select all that apply.
I agree
Signed
*
Date
*
Submit
Description
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