Live - Birmingham United Methodist Church

Student Information 2022-2023

Student's Name(Required)

Date of Birth(Required)

Grade(Required)

School(Required)

Student Cell Phone

If applicable.

Do we have permission to contact your child on their cell phone?

Yes

Is your student on Instagram?

Yes

Student Email

If applicable

Address

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

Name of Parent or Guardian(Required)

Parent/Guardian Cell Phone(Required)

Parent/Guardian Email(Required)

Name Additional Parent or Guardian

Parent/Guardian Cell Phone

Parent/Guardian Email

Emergency Contact(Required)

In case of an emergency, who should we contact?

Relationship to Student(Required)

Emergency Contact Phone(Required)

Insurance Company(Required)

Name of Insurance Holder(Required)

Policy Number(Required)

Does your child have any allergies?

Does your child have any special needs (learning, emotional, physical, behavioral) or anything you want us to know?

Does your child have any special dietary needs?

List any people that are allowed routinely to pick up your child from youth activities.