Student Ministries Info Sheet/files/Student Ministry/tio sam_1.gif

"We need YOUR info"

First Name:   

Last Name: 

Male:   Female:  

D.o.B:

Address:   

City:   State:  

Zip:    Home Phone:  

Student Cell:

Grade:    School:   

Activities? 

Father's Name:  

Mother's Name:

Stepmother's Name:  

Stepfather's Name: 

With whom do you live? 

Parent Cell Phone:   

Parent Work Phone: 

Emergency Contact Name:   

Emergency Contact Phone:

Student email:  

Parent email:

Where do you go to church?   

Hobbies/Interests? 

Would you be interested in a Bible Study?   

Would you like to be contacted?   Yes    No

Do you have any brothers or sisters?    If so, please give names, grade & ages: