Student #1
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Complete only the # of child(ren) enrolled in the Salem Student Program. When you have completed all sections please scroll to the bottom and hit submit.
*
Indicates required field
# of Children included in this form
*
1
2
3
4
5
I need more options and will fill out another form to include additional children.
#1 Child Information
#1 Child Name
*
First
Last
Address
*
Same as Parent / Guardian
Different - Pls fill out below
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Birthday
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
1
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Year
*
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Age
*
> 12 mos.
13-23 mos.
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Grade
*
Not enrolled in school
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Gender
*
Male
Female
Allergies
*
Emergency Contact and #
*
#2 Child Information
form-not-required
*
First
Last
form-not-required
Address - If the same as Child #1 leave blank
*
Line 1
Line 2
City
State
Zip Code
Country
Birthday
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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29
30
31
Year
*
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Age
*
> 12 mos.
13 - 23 mos.
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Grade
*
Not Enrolled In School
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Gender
*
Male
Female
Allergies
*
Emergency Contact and #
*
#3 Child Information
#3 Child Name
*
First
Last
Address - If the same as Child #1 leave blank
*
Line 1
Line 2
City
State
Zip Code
Country
Birthday
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Age
*
> 12 mos.
13-23 mos.
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Grade
*
Not enrolled in school
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Gender
*
Male
Female
Allergies
*
Emergency Contact and #
*
#4 Child Information
#4 Child Name
*
First
Last
Address - if the same as Child #1 leave blank
*
Line 1
Line 2
City
State
Zip Code
Country
Birthay
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2020
2021
2022
Age
*
> 12 mos.
13 - 23 mos.
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Grade
*
Not enrolled in school
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Gender
*
Male
Female
Allergies
*
Emergency Contact and #
*
#5 Child Information
#5 Child Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Birthday
Month
*
Option 1
Option 2
Option 3
Day
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Age
*
> 12 mos.
13 - 23 mos.
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Grade
*
Not enrolled in school
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Gender
*
Male
Female
Allergy
*
Emergency Contact and #
*
Submit
Welcome
First Time Guests
>
Who We Are
>
Eternal Life
Our Beliefs
History & Future
Digital C.A.R.E. Card
Becoming A Member
Staff Contacts
Worship
Connect
Preschool & Children
>
AWANA
Student Enrollment
Salem Students
>
Salem Student Health Questionnaire and Medical Consent
Adult
>
Choir
>
Practice Music
Legacy Seniors
>
Day Trips
Missions
Trunk or Treat
Pray For Me
C.A.R.E.
Hope For the Hungry
Resources
CPR TRAINING
Social Media
>
Facebook Groups
SERMONS
Announcements
>
Announcements List
Calendar
SERVE AT SALEM
Photo Directory
Salem Swag
Contact
Forms
>
Salem Student Health Questionnaire and Medical Consent
Español
Estudio Biblico Bilingüe
Estudio bíblico de mujeres
Servicio Bilingüe
Stream
Give
