Student Information Collection Form

Student Registration Form

Complete One Per Student Per Semester
COACH Location*
General Information

Please fill out one per student (per school year)
School Year*
Semester*
Did You Attend Last Semester?*
Student Name*

First NameMiddle NameLast Name
Student's Preferred Name
Nickname/Name they prefer to be called
Student's Grade Level (for the school year selected)*
Student's Email (create a Gmail email account if he/she does not have an email)*
example@example.com
Student's Phone Number (if he/she has one)
Please enter a valid phone number.
Student's Birth Date*

MonthDayYear
Student's Gender*

Family Information
Parent or Guardian On-Campus with the student*

First NameLast Name
Additional: Parent(s), Guardian(s) or Other Name(s)
What is your relationship with the student?*

ParentGuardianOther
If Other, please explain your situation.
Main Email Address for Correspondence
example@example.com
Sibling(s) Name(s)
Residence Information
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code

Emergency Contact Information
Primary Emergency | Contact Name*

First NameLast Name
Primary Emergency | Phone Number*
Please enter a valid phone number.
Primary Emergency | What is his/her relationship to this student?*
Secondary Emergency | Contact Name

First NameLast Name
Secondary Emergency | Phone Number
Please enter a valid phone number.
Secondary Emergency | What is his/her relationship to this student?

Medical Information
Physician Name

First NameLast Name
Physician Primary Phone Number
Please enter a valid phone number.
Physician Secondary Phone Number
Please enter a valid phone number.
Preferred Emergency Hospital Name
Please list any of the followings: current medications, medication allergies, food allergies, or chronic health concerns.

Additional Information
Student Bio for the Student Directory - Have you student tell us about themselves. What grade they are in, hobbies, sports, etc.*
Do you want your student included in the Student Directory?*

YesNo
We regularly take photos on campus during class activities and events for use in marketing materials, our private Facebook group, and the yearbook. Your child may appear in these photos. If you prefer that your child not be included in these public or group photos, please let us know so we can respect your preference. However, please note that we do require a photo of your child for our COACH records for security purposes. This photo will be used internally only on a HIPAA compliant server and will not be shared publicly.*

Yes, I give permission of this photo release for these purposesNo, I do not want photos of my student taken. However, I allow this uploaded photo of our child for COACH records for security purposes. and understand that the photo will be used internally only on a HIPAA compliant server and will not be shared publicly.
Upload Student Headshot Photo - For Student Directory & Admin Files (jpg, png, gif)*

Cancelof
If your student is in High School, please have each of your students read the Statement of Faith, Handbook, and Dress Code. If your student is in 8th grade or younger, please make them aware of important policies and as their guardian you may hold them accountable to abide by them and you may sign for them below. ***PLEASE READ*** COACH Statement of Faith, Handbook, and Dress Code. By signing this I agree that:

I have read and will abide by the Statement of Faith, Handbook, and Dress Code.
Your student's signature (or for children 8th grade and younger, the parent may sign on his or her behalf)

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Student Registration Form

General Information

Family Information

Residence Information

Emergency Contact Information

Medical Information

Additional Information