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Student Consent and Release Form
Please be sure you have reviewed the Student Ministry Program enrollment information at
www.glencoefbc.com/#enroll
before filling out this form. Form MUST be filled out by a parent or guardian.
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* Indicates required question
1. Child's Name
*
Your answer
Age
*
Your answer
Grade
*
Your answer
Birthday
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Medical Conditions or Allergies
Your answer
Family Information
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Mother's Name
Your answer
Mother's Phone #
Your answer
Father's Name
Your answer
Father's Phone #
Your answer
Guardian's Name
Your answer
Guardian's Phone #
Your answer
Do you have more children to add?
*
Yes let me add more children
No I'm done
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