EmailMe Form - Registration Form 2014

Full Legal Name of Student *

First Middle Last

Place of Birth *

Grade Applying For *

Gender *

Male

Female

Age (Yr/Mo) *

Birthday (MM/DD/YYYY) *

Church Membership *

If SDA: Date Baptized

Best Home Phone *

### - ### - ####

Best Cell Phone *

### - ### - ####

Child Lives With *

Both Parents

Mother

Father

Other

Info is required below depending on which box above is checked. If both parents, then both mother and father info required, if other then that one is required.

IF MOTHER/BOTH PARENTS: Mother's Name

First Last

Home Address

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

Mailing Address (If different from Home Address)

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

Mother's Occupation

Mother's Business Phone

### - ### - ####

Mother's Email Address

Mother's Church Membership

IF FATHER/BOTH PARENTS: Father's Name

First Last

Home Address

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

Mailing Address (If different from Home Address)

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

Father's Occupation

Father's Business Phone

### - ### - ####

Father's Email Address

Father's Church Membership

IF OTHER IS SELECTED PLEASE FILL OUT INFO: Other's Name

First Last

Home Address

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

Mailing Address (If different from Home Address)

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

Other's Occupation

Other's Business Phone

### - ### - ####

Other's Email Address

Other's Church Membership

Emergency Contact Info

Contact Name *

First Last

Phone *

### - ### - ####

Family Physician *

Family Physician Phone *

### - ### - ####

Info is required below depending on which box above is checked. If both parents, then both mother and father info required, if other then that one is required.

Emergency Contact Info

When the form is all filled out, please select the Submit button below. Thank you.