Trinity Registration for Student/Child 2018-2019 Survey

1.Contact Information for Student/Child 1 (Part 1 of 2)(Required.)

Name of Student/Child 1

Address

City/Town

Zip Code

Email Address of Student 1 (if appropriate)

Cell Phone # of Student 1 (if appropriate)

Birthday of Student/Child 1 (mm/dd/yy)

Age of Student/Child 1

Grade in School

Name of School

2.Personal Information for Student/Child 1 (Part 2 of 2)(Required.)

Name of Student/Child 1

Is Student/Child 1 baptized? (yes or no)

Would you like Pastor Brian to contact you about baptism for Student/Child 1? (yes or no)

Please list Student/Child 1's allergies, if any.

Please list Student/Child 1's medications, if any.

Please describe Student/Child 1's individualized educational program (IEP), if any.

Please describe Student/Child 1's special needs, if any.

3.Contact Information for Student/Child 2 (Part 1 of 2)

Name of Student/Child 2

Address

City/Town

Zip Code

Email Address of Student 2 (if appropriate)

Cell Phone # of Student 2 (if appropriate)

Birthday of Student/Child 2 (mm/dd/yy)

Age of Student/Child 2

Grade in School

Name of School

4.Personal Information for Student/Child 2 (Part 2 of 2)

Name of Student/Child 2

Is Student/Child 2 baptized? (yes or no)

Would you like Pastor Brian to contact you about baptism for Student/Child 2? (yes or no)

Please list Student/Child 2's allergies, if any.

Please list Student/Child 2's medications, if any.

Please describe Student/Child 2's individualized educational program (IEP), if any.

Please describe Student/Child 2's special needs, if any.

5.Contact Information for Student/Child 3 (Part 1 of 2)

Name of Student/Child 3

Address

City/Town

Zip Code

Email Address of Student 3 (if appropriate)

Cell Phone # of Student 3 (if appropriate)

Birthday of Student/Child 3 (mm/dd/yy)

Age of Student/Child 3

Grade in School

Name of School

6.Personal Information for Student/Child 3 (Part 2 of 2)

Name of Student/Child 3

Is Student/Child 3 baptized? (yes or no)

Would you like Pastor Brian to contact you about baptism for Student/Child 3? (yes or no)

Please list Student/Child 3's allergies, if any.

Please list Student/Child 3's medications, if any.

Please describe Student/Child 3's individualized educational program (IEP), if any.

Please describe Student/Child 3's special needs, if any.

7.Permissions (check all that apply)(Required.)

MEDICAL TREATMENT - YES. As a parent or guardian, I do herewith authorize treatment of the above minor(s) by a qualified licensed doctor in the event of a medical emergency, which in the opinion of the attending physician may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me by telephone.

PHOTOGRAPHY - YES. I will allow my child/children to be photographed to share information about the ministries of Trinity Church.

8.Emergency Information(Required.)

Name of Parent or Guardian

Cell Phone # of Parent/Guardian

E-Mail of Parent/Guardian

Name of Emergency Contact (adult not in the building)

Relationship to Student/Child

Best Phone # of Emergency Contact

Insurance Company

Policy Number

Name of Policy Holder

Phone Number to Verify Coverage

9.My Safe Sanctuary Commitment (check all that apply)

I will read the Trinity Church Safe Sanctuary Policy (for everyone).

I will agree to a simple background check (for volunteers and helpers).

I will complete the basic online training for Safe Gatherings (for leaders and staff).

Current Progress,

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