Student Connect Form

Student Info

First Name

Last Name

Gender

Male

Female

Email (Leave blank if not applicable)

Phone Number (Leave blank if not applicable)

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Birthdate

Grade

School

School Extracurriculars

Medical Note (Please let us know about any food/substance allergies, disabilities, or other needs. Type "N/A" if none apply.)

Mother's Information

First Name

Last Name

Phone Number

Email

Marital Status

Do you attend LifePoint?

Yes

No

Father's Information

First Name

Last Name

Phone Number

Email

Marital Status

Do you attend LifePoint?

Yes

No