Register Your Student

Student Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Student Current Age/Grade for 2021-2022 School Year*
Student Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Has your child been diagnosed with any physical or developmental disability? (Example: Diabetes, Epilepsy, ADHD, Cerebral Palsy, Autism, or any other medical condition.) Please explain below to help us understand & effectively minister to your student.*
Does your child have any allergies? Please list the allergy, cause and effect, and what immediate treatment is necessary. Note: snacks may be given.*
Parent/Guardian Name*
First Last
Relationship to Student*

(father, mother, grandparent, etc...)
Parent/Guardian Cell Phone*
Parent/Guardian Name
First Last
Relationship to Student

(father, mother, grandparent, etc...)
Parent/Guardian Cell Phone
Parent/Guardian Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Parent/Guardian Email
Parent/Guardian Email
What is the best way to reach you?*
- Select All
- Text
- Phone Call
- Email
Consent to Photograph*
By selecting "I agree," I authorize Neshannock Alliance Church ministries to photograph my child during church activities for the purpose of power point presentations, slides, bulletin board displays, scrapbooks, and/or advertisements of church events.
Verification*
By checking the box, I certify that I am at least 18 years of age and I am the child's parent or legal guardian.