Student Information

First Name:
Middle Name:
Last Name:
Preferred/Nickname:
Address:
City, State, Zip:
Home Phone:
Student's Cell Phone:
Date of Birth:
Email:

Parent Information

Are parents members of Westminster? Parent 1       Parent 2       Both       Neither      
Parent 1
Name:
Home Phone:
Cell:
Work Phone:
Address:
City, State, Zip:
Email:
Parent 2
Name:
Home Phone:
Cell:
Work Phone:
Address (if different from Parent 1):
City, State, Zip:
Email:
Emergency contact (if mom/dad can’t be reached)
Name:
Phone:

School

Current School:
Grade:
After-school Activities:

Special Needs

Please tell us about any special needs or challenges your child has


Stuff We Left Out

Tell us anything else we need to know


Medical Information

Please check the following areas of concern for this student:

Does your child have allergies to:

Medication (please explain):
 
 
None

Does your child currently, or have they ever, suffered from or been treated for any of the the following:

 
 
 
 

Should your child's activities be restricted for any reason? Please explain:

Please list any other important information we should know about your child:


Photo/Video Release

I understand that by participating in Sunday School and its associated activities, my son/daughter will be photographed and videotaped. I hereby assign and authorize the producer, Westminster Presbyterian Church, the rights (all rights) in and to such videotape and photography. I also authorize said producer, without limitation, the right to reproduce, copy, exhibit/publish, and distribute any such videotape and/or photographs, and expressly waive any rights or claims I may have against Westminster and/or any of its Affiliates, Subsidiaries, or Assignees except as outlined in this contract.

May we publish photographs of your child in print?

May we publish photographs of your child on our website?

May we video your child and upload videos to our website?

Students will not be identified by name in any of these publications.