Student Contact Information

Monday Night Alive in Colington
Student Contact Information


Student ________________________________ Date __________


M/F _____________ DOB _________________ Grade ________
Parent/Guardian Info (if Guardian, please provide additional relationship info)
#1 Name Relationship to student
_________________________________ ( )mother ( )father ( )guardian
Phone (home/cell)
_________________________________
Employer Phone
____________________ ___________
#2 Name
_________________________________ ( )mother ( )father ( )guardian
Phone (home/cell)
_________________________________
Employer Phone
____________________ ___________
#3 Name
_________________________________ ( )mother ( )father ( )guardian
Phone (home/cell)
_________________________________
Employer Phone
____________________ ___________
Student’s Physical Address ________________________________________
Mailing Address (if different from above) _____________________________
Emergency Contact (other than parent/guardian listed above)
Name Relationship Phone
________________________________ __________________ 
________________________________ __________________ 
Please provide the names and relationship of all individuals living in the home with this student.
________________________________________________________________________________________________________________
________________________________________________________
Thank you for entrusting your child to MNAC. Please use the back of this paper to provide additional student information
(food allergies, emotional or medical conditions) to assist program tutors and helpers in making this a successful experience for your child.

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