Harlem's Youth Ministries Student Information Form 2017
Please fill out this form for each student who will be attending ministries at Harlem Reformed Church.
Ministries student will be involved in:
*
Please select all that apply.
Sunday School
GEMS/Cadets
VBS
Children's Church
Senior High Youth
Junior High Youth
Student Information
Student's Name
*
Age
*
Grade
*
Please select one option.
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Select Option
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Gender:
*
Please select one option.
Male
Female
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
Birth Date
Student Cell Phone
Student Email
School Student Attends
*
Parent/Legal Guardian Information
Parent/Legal Guardian Name
*
Home Phone
*
Cell Phone
Work 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:
Please list any special interests, hobbies, or jobs your student may have:
Other information regarding your student that would be helpful for counselors/teachers:
Names of any siblings attending:
Insurance Information
Physician
*
Office Phone
*
Insurance carrier and 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. I also release Harlem Reformed Church, their staff and volunteers from any liabilities that could result from unintentional accidents and/or self inflicted harm. I also give permission for him/her to receive medical treatment deemed necessary by appropriately trained medical personnel. I also give permission for the use of photographs in which they are included for church publicity.
*
Please select all that apply.
I agree
Signed
*
Date
*
Submit
Description
Please fill out this form for each student who will be attending ministries at Harlem Reformed Church.
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