Student's Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Student's Phone # *

(###)

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Parent/Guardian Phone # *

(###)

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Parent/Guardian Phone #

(###)

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate *

MM

DD

YYYY

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone # *

(###)

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Emergency Contact Alternate Phone #

(###)

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As the Parent/Guardian of the youth named in this document: (Please Check one) *

I hereby give permission to Pleasant Grove Baptist Chruch to use my child's photographic likeness in related church publications and websites for any lawful purpose.

I do not give permission for my child's photographic likeness to be used by Pleasant Grove Baptist Church.