EmailMe Form - 2018 Community Reading Academy Registration

Student Name *

First Last

Grade Student was enrolled in for school year 2017-18 *

Student Birthdate *

MM / DD / YYYY

Parents/Guardian Name(s) *

Mailing Address *

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

Home Phone *

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

Cell Phone *

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

Email Address *

Medical Information:
Does your child have any allergies or special needs that we should be aware of? *

Emergency Contact *

First Last

Phone *

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

Alternate Emergency Contact

First Last

Phone

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

Guardian Signature *

Date Time *

MM / DD / YYYY

St. James Missionary Baptist Church
3714 E. MLK Blvd, Austin, TX 78723
(512) 928-2753
www.stjamescmbc.org