Student Information Collection Form

Student Registration Form

Complete One Per Student Per Semester
COACH Location*
General Information

Please fill out one per student (per school year)
School Year*
Semester*
Student Name*

First NameMiddle NameLast Name
Student's Preferred Name
Nickname/Name they prefer to be called
Student's Grade Level (for the school year selected)*
Student's Email (create a Gmail email account if he/she does not have an email)*
example@example.com
Student's Phone Number (if he/she has one)
Please enter a valid phone number.
Student's Birth Date*

MonthDayYear
Student's Gender*

Medical Information
Physician Name

First NameLast Name
Physician Primary Phone Number
Please enter a valid phone number.
Physician Secondary Phone Number
Please enter a valid phone number.
Preferred Emergency Hospital Name
Please list any of the followings: current medications, medication allergies, food allergies, or chronic health concerns.

Additional Information
Student Bio for the Student Directory - Have you student tell us about themselves. What grade they are in, hobbies, sports, etc.*
Upload Student Headshot Photo - For Student Directory & Admin Files (jpg, png, gif)*

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If your student is in High School, please have each of your students read the Statement of Faith, Handbook, and Dress Code. If your student is in 8th grade or younger, please make them aware of important policies and as their guardian you may hold them accountable to abide by them and you may sign for them below. ***PLEASE READ*** COACH Statement of Faith, Handbook, and Dress Code. By signing this I agree that:

I have read and will abide by the Statement of Faith, Handbook, and Dress Code.
Your student's signature (or for children 8th grade and younger, the parent may sign on his or her behalf)

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Student Registration Form