Updated 2025-2026 Student Registration Form

Student #1 Information

Student Name

Phone (if student has one)

Email (if student has one)

Student Address

Gender

Male Female Other

Birthdate

School Name & District

Student Membership of Zion/Profession of Faith

Baptized Member of Zion Personally Professed Faith/Confessing Member Attend Zion but not a member Member of another church Attend another church Don't attend any other church Other

Physician

Physician phone #

Immunizations current?

Yes No Other

Can student receive over-the-counter medication from staff or leaders (Tylenol, Benadryl, etc)

Is student able to participate in all activities? If not, please explain

Does student have any food allergies or dietary restrictions? If yes, please explain

Does student have any other allergies? If yes, please explain

Does student have any pre-existing conditions (ADHD, Depression, Anxiety, Autism Spectrum, etc)? If yes, please list and explain if any accommodations need to be made.

Does your student take any prescription medication that we should be made aware of? If yes, please list the medications and explain

Any other special conditions or accommodations we should be made aware of? If yes, please explain.

Student #2

Full Name Student #2 Name

Gender

School Name and District

Birthdate

Phone (if student has one)

Email (if student has one)

Student Membership

Address (if different from student #1)

Physician (if different from student #1)

Physician Phone Number (if different from student #1)

Immunizations Current Yes No Option

Can Student receive over-the-counter meds from staff or leaders (Tylenol, Benadryl, etc..)

Is student able to participate in all activities? If no, please explain

Does student have any food allergies or dietary restrictions? If yes, please explain

Does student have any other allergies? If yes, please list and explain

Does student have any pre-existing conditions (ADHD< Depression, Anxiety, Autism spectrum, etc?). If yes, please list and explain any accommodations that may need to be made

Does student take any prescription medications that we should be aware of? If yes, please list and explain

Student #3

Full Student #3 Name

Phone (if student has one)

Email (if student has one)

Address (if different than other students in family)

Gender Male Female Other

Birthdate

School Name and District

Student Membership

Physician (if different than other students)

Physician # (if different than other students)

Immunizations Current? Yes No Other

Can this student receive over-the-counter meds from staff or leaders (Tylenol, Benadryl, etc)?

Is this student able to participate in all activities? If no, please explain

Does this student have any food allergies or dietary restrictions? If yes, please explain

Does this student have any other allergies? If yes, please explain

Does this student have any pre-existing conditions (ADHD , Autism Spectrum, Anxiety, etc.)? If yes, please list and explain and list any accommodations that need to be made

Does this student take any prescription medications that we should be made aware of ? If yes , please list and explain

Are there any other special concerns or accommodations this student may need? If yes, please explain

Parent/Guardian 1

Full Name

(Cell) Phone

This address will receive a confirmation email

Physical Address (if different from Student Address)

Mailing Address (if different from Physical Address)

Parent/Guardian 2

Full Name

(Cell) Phone

This address will receive a confirmation email

Address (if different from Student Address or Parent/Guardian 1)

Parent/Guardian 3 (if applicable)

Full Name

(Cell) Phone

This address will receive a confirmation email

Address (if different from other addresses)

Emergency Contact Person (Other than Parent/Guardian)

Name

Relationship to Student or Guardian

(Cell) Phone

Medical Information

Insurance Company

Insurance Policy Number

Group Number

Release of Liability & Media Release

By signing this form, I hereby certify that the above information is correct and grant permission for the use of photographs and videos including my child(ren) for use on social media, Zion’s website or for in house publicity; for my child(ren) to be transported to and from off campus activities; for the release of medical records in case of illness or injury; and for the student(s) named herein to engage in all activities except as noted by me. I also give my permission to the physician selected by Zion to secure proper medical treatment for the student(s) named herein in case of illness or injury. If any changes on this form occur before September 1, 2025, I agree to notify Zion Reformed Church and it's staff of these changes.

Today's Date

*Electronic Signature

*By entering my name in the box above, I am providing my digital signature for this field.

Updated 2025-2026 Student Registration Form

Description

Please Fix the Following