Parent/Guardian & Emergency Contact
Please fill out the following information of the youth's Parent/Guardian and Emergency Contact. Parent/Guardian 1 must provide complete information. Parent/Guardian 2 information is not required. To enter more than two Parent/Guardians, please email Brandon Heath (bheath@christlamesa.org) with their info.
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Email *
Parent 1 First and Last Name *
Parent 1 Cell Phone Number *
Parent 1 Email *
Family Address *
Family City, State Zip *
Parent 2 First and Last Name
Parent 2 Cell Phone Number
Parent 2 Email
Parent 2 Address
If different from Parent 1 address
Parent 2 City, State Zip
If different from Parent 1 City, State Zip
Emergency Contact First and Last Name *
Emergency Contact Cell Phone Number *
Relationship to Student *
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