Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (or guardian's phone) *

(###)

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IEP *

Are there any special education serivces (IEP, 504 Plan, etc.) provided to your student?

Yes

No

Counseling

I am interested in my student recceiving counseling through Freedom.

Yes

No

Parent/Guardian Permission

By checking this box and providing my information below, I give my child permission to participate in activities with adult supervision as listed above and therefore remove all liability and responsibility from Freedom for Youth Ministries

Parent or Guardian Name *

First Name

Last Name

Parent or Guardian Phone *

(###)

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