Confirmation Registration 2020

Address *

Line 1

Line 2

City

State

Zip Code

Country

Parent Mobile Number 1 *

Parent Mobile Number 2 *

Home Number *

Parent Email 1 *

Parent Email 2 *

Parent/Guardian's Name *

First

Last

Member of *

Calvary Redeemer Zion Other / None of the above

Parent/Guardian's Name *

First

Last

Member of *

Calvary Redeemer Zion Other / None of the above

Student's Name *

First

Last

Name of (Requested) Faith Mentor *

First

Last

Student's Mobile Phone Number *

Student 2 Name *

First

Last

Name of (Requested) Faith Mentor *

First

Last

Student's Mobile Phone Number *

Student Living with *

Both Parents Mother Father Guardian

Are there any legal custody restriction we should be aware of? *

Yes No

Emergency Contact 1 *

First

Last

Mobile Phone Number *

Emergency Contact 2 *

First

Last

Mobile Phone Number *

Please advise us of any relevant condition, allergies, learning disabilities or other issues *

Does the student require EpiPen *

Yes No

Does the student require a one-on-one aide during the school day *

Yes No

Confirmation Registration 2020-2021