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) *

(###)

###

####

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. Please note that counseling is not available during the Summer).

Yes

No

Program Session

Plesae register my student for the following session(s):

Summer (2025)

Fall (2025)

Spring (2026)

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 *

(###)

###

####

Emergency Contact (if different from other guardian information)

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Field Trip Permission *

I give Freedom permission to take my student on field trips off campus.

Yes

No

Van Transportation Permission *

I give Freedom permission to pick up and take home students to and from program in our 16-passenger vans.

Yes

No

Committment Statement *

I am committed to my student attending Freedom consistently or their spot may be given to a student on the waitlist.

Yes

No