Bethany Christian Schools

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Student Name: *

name of student in grade 4-6

Gender: *

Male

Female

Grade:

4

5

6

Sport: *

boys basketball

girls basketball

volleyball

Street Address: *

City: *

State: *

ZIP: *

Email:

Email to send confirmation and information

Parent/Guardian Name: *

Phone Number: *

Contact phone of parent/guardian where student resides

Emergency Contact:

name of someone to contact in case of emergency other than parent/guardian

Emergency Phone:

Phone number of Emergency Contact

Spam Blocker: *

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