First-Centenary United Methodist - The Centenary Registration

Parent/Guardian's First Name

Last Name

Parent/Guardian's Email

Parent/Guardian's Phone Number

Secondary Parent/Guardian (name, relationship to student, phone number, email address) - optional

Student's Full Name

Student's Birthdate

Student's Home Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Student's School and Grade for This Year

Student’s Powerschool (number and password) - optional

First Emergency Contact (name and phone number) - not parent/guardian

Second Emergency Contact (name and phone number) - not parent/guardian

Student’s Health Insurance Carrier (policy number and group number)

Student’s Physician (name and phone number)

Student Allergies (if any)

Does the student carry an EpiPen?

Yes

No

Does the student have asthma?

Yes

No

If yes, list name of medication and dose.

List any health conditions, or medicines taken by the student, of which The Centenary should be aware.

The Centenary Registration

Member of the:
Holston Conference
Scenic South District

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