Parent/Guardian*
Email*
Cell Phone*( ) -
Teen's*
Age*
Birthday* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Sporadically/few times per year
1-2 x per month
2 or more x's per month
Any dietary/food restrictions we should be aware of?*
Is there anyone else you authorize to pick up your teen from Teen's Ministry? If so, please give their name, relation and cell # below.*
Does your teen have any special needs/disabilities or (i.e. physical, verbal, visual, audio, mental, mobility, etc.) requiring special assistance? If so, please list them and the best way to serve your teen during service.*
Does your teen have any behavioral or mental health challenges? If so, please list them and the best way to respond to your teen during service.*
Does your teen have any medical conditions we need to be aware of during a typical service (i.e. injuries, allergies, TBI, vision, infections, diseases, etc.) ? If so, please list them and the best way to respond to your teen during service.*
Any other comments you would like to share that would help us while we care for your teen?*
