Child Info Form

Name of Child/Teen(Required)

First Last

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email (for teen)

Cell Phone (for teen)

Date of Birth(Required)

Grade Placement for THIS School Year(Required)

(If you are completing this in the summer, please indicate which grade your child/teen will be in when the new school year starts. If your child is between the ages of 0 - 4 years old, please indicate how old your child will be on September 1.)

Gender(Required)

Allergies(Required)

Does the child/teen have an EpiPen or inhaler?(Required)

Yes

Is there anything else that would be helpful for us to know about your child/teen and his/her developmental, behavioral, emotional, or educational needs?(Required)

Siblings (please include name and age/grade)(Required)

Name for Parent/Guardian 1(Required)

First Last

Relationship to Child/Teen(Required)

Email(Required)

Cell Phone(Required)

Name for Parent/Guardian 2

First Last

Relationship to Child/Teen

Cell Phone

As the parent/guardian of the child/teen listed on this form, I can verify that all the information on this form is accurate to the best of my knowledge.(Required)

Yes

I grant permission for my child/teen’s picture to be used within the VanChurch building and/or on the website.(Required)

Yes

Parent Signature(Required)

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Submission Source

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Submission Medium

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Submission Campaign

Child Info Form

Information

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