Confidential Capernaum Student Questionnaire

Please take a few moments to complete the informational form below.  This information is confidential and we appreciate you taking the time to fill this form out.  Your input will help us know how to best serve your son or daughter!  If you have any questions, please feel free to contact us.

Student's Name *
Student's Name
Parent(s) or Guardian Name *
Parent(s) or Guardian Name
Address *
Address
Home Phone *
Home Phone
Parent Cell Phone *
Parent Cell Phone
Student's Date of Birth *
Student's Date of Birth
Student Allergies? *
(e.g., food allergies)