Student's First Name Student's Last Name Student's nickname: please enter the name your child prefers to be called Student's Birthdate (dd/mm/yyyy) Student's Grade (entering) Child must be at least 4 yrs. old. Please select one: Pre K- 4 Yrs. Old Kindergarten First Grade Second Grade Third Grade Fourth Grade Fifth Grade Sixth Grade Seventh Grade 8th Grade High School Parent/ Guardian Name Filling Out this Form Mother's Name: please enter full name Father's Name: please enter full name Emergency Contact Phone # Home Phone # E-mail address Please indicate what to do in case of emergency. Please select one: Take to nearest Hospital (Southern Ocean Medical Ctr) Take to preferred Hospital (indicate name below) Neither - please explain below in Medical Information box. Student Medical Information. Please include allergies and name of preferred Hospital if applicable. Please explain anything else we should know. Information is kept confidential and will only be used to better serve your child. Are you a member of MUMC? Yes No Would you like information on becoming a member? Yes No Not at this time Please indicate your release for photos to be posted. Please select one: Bulletin Board only - inside church building or classroom Bulletin Board, Church Website (on line) Crossword Newsletter Do not print photos Please indicate if your child's name can be printed with photo. Yes No
