Senior Pastor or Youth Pastor Phone Number Christian? Yes No Religion Father’s Religious Belief □ □ □ Christian? Yes No Other Religion Mother’s Religious Belief □ □ □ Yes No Is the student a born believer in Jesus Christ? □ □ Medical Information Family Doctor Number Yes No Does the student have any □ □ allergies/chronic illness? If yes, then please specify: Yes No Does the student use any medical devices? □ □ If yes, then please specify: Yes No Has the student been identified as having a □ □ learning disability? If yes, then please specify: Has the student received the following immunizations? (attach an original copy of the student’s immunization records) Hepatitis B MMR HPV □ □ □ Diphtheria (DPT) Smallpox Polio □ □ □ Scholastic Information Last School Attended School Address School Phone # School Fax # □ □ Has the student ever been expelled, suspended, dismissed from school, or refused admission to Yes No another school?
Senior Pastor or Youth Pastor Phone Number Father’s Religious Belief Christian? Yes □ No □ Religion □ Mother’s Religious Belief Christian? Yes □ No □ Other Religion □ Is the student a born believer in Jesus Christ? Yes □ No □ Medical Information Family Doctor Number Does the student have any allergies/chronic illness? Yes □ No □ If yes, then please specify: Does the student use any medical devices? Yes □ No □ If yes, then please specify: Has the student been identified as having a learning disability? Yes □ No □ If yes, then please specify: Has the student received the following immunizations? (attach an original copy of the student’s immunization records) Hepatitis B □ MMR □ HPV □ Diphtheria (DPT) □ Smallpox □ Polio □ Scholastic Information Last School Attended School Address School Phone # School Fax # Has the student ever been expelled, suspended, dismissed from school, or refused admission to another school? Yes □ No □
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