First Name
Last Name
Address ?
Include your address, city, and zip
Phone Number
Example: 734-555-5555
Parents Email Address
Child's name
First, and last name.
Age of student with birthdate
Example: 6 years old 03/15/2009
Last Grade Completed
Enter a grade level, or If homeschooled please mention.
Medical Information and/or allergies
Emergency Contact ?
Names, Home, work, and Cell phone numbers
Dismissal Information
Who will be picking up your child.
Church Affiliation
Which church do you belong to?
Do you attend church?
If Yes, which Church do you attend?
Are you visiting?