Student and Family Information

Please complete the information below.

Child's Name: Child's Name: First Middle Last
Male Female
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Birth Date: Birth Date: / MM / DD YYYY
Are You a Member of a Church
Have you been Baptized?
If yes, what church?
If Yes, where and the date you were baptized?
To Whom is the Child to be Released?

Please enter the names below.
1. Name 1. Name First Last
2. Name 2. Name First Last
3. Name 3. Name First Last
4. Name 4. Name First Last
Parent Information:

Parent Information: Married Seperated Divorced Remarried Guardianship Other Other
Who has legal custody?
Child lives with:
Custodial Parent's Information
Custodial Father's Background
Name: Custodial Father's Background
Name: First Middle Last
Custodial Monther's Background
Name: Custodial Monther's Background
Name: First Middle Last
Address, if different than above: Address, if different than above:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Address, if different than above: Address, if different than above:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Workplace:
Workplace:
Work Phone: Work Phone: - ### - ### ####
Work Phone: Work Phone: - ### - ### ####
Cell Phone: Cell Phone: - ### - ### ####
Cell Phone: Cell Phone: - ### - ### ####
Email
Email
Brothers/Sisters of child listed above:
1. Name:
Birthday:
Age:
School Attending:
2. Name:
Birthday:
Age:
School Attending:
Special Limitations

Please complete the information below.
Drop Down
If Yes, please list:
What physical restrictions does this child experience?
Has this child been involved in Special Education?
Has this child been involved in Speech?
If Yes, where?
If Yes, where?

Student and Family Information

Student and Family Information

To Whom is the Child to be Released?

Custodial Parent's Information

Brothers/Sisters of child listed above:

Special Limitations