Emmanuel Student Ministries

Student Name * First Last
You should know your name. Just make sure WE know it!
Parent/Guardian Name * First Last
Your parents have names too. Pick one, and put it here!
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Do you know where you live? Good! Now we need to know.
Home Phone Number * ### - ### - ####
Who should we call in case of emergency? (Like we run out of pizza!)
Parent's Email *

We're going to send the confirmation to this email address, so make sure your parents check for it!
I am interested in a confidential scholarship.

Don't let money keep you from coming! Seriously. If $49 is a little steep, just check this box.
Gender *
Male Female

If you don't know, ask a parent.
One friend you want in your room.

Must be same gender.
Do Not Fill This Out

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