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HCC Student Registration Form
Havana Church of Christ Student Ministries / Pastor Paul Webster
350 S. Broadway Street / Havana, IL 62644 /
havanachurch.com
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* Indicates required question
Student's Name
*
Your answer
Grade
*
Grade student is currently in.
Choose
Pre-K
K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
D.O.B.
*
MM
/
DD
/
YYYY
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Email
*
Your answer
Home Phone
*
Your answer
Cell Phone
*
Your answer
Parent's Legal Guardians' Names (with whom you live):
*
Your answer
Health Insurance Company
*
If None type N/A
Your answer
Policy #
*
If None type N/A
Your answer
Known Allergies and Reactions
*
If None type N/A
Your answer
Medications Currently Taking
*
If None Type N/A
Your answer
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