HPUMC Students

Student Information

Student Full Name:*

Date of Birth:*

(Format: mm/dd/yyyy)

Home Phone:*

Street Address:*

City, State, Zip*

Student Cell

Do you text message?*

Yes
No

Student Email:*

Do you use Facebook?*

Yes
No

What is the best way to contact you? (choose all that apply)*

email
facebook
cell - Call
cell - text

School Name:*

High School Graduation Year:*

Parent / Guardian Information

Parent #1 Name:*

Parent #2 Name:

Other Parents Names:

Parent #1 Cell Phone:*

Parent #2 Cell Phone:

Other Phone:

Parent #1 Email*

Parent #2 Email:

Other Email:*

Emergency Contact Information

Name (not above listed Parent)*

Phone:*

Student and Parent Agreement

Parent Agreement:*

As the Parent of this student, I agree to support them in this program
I understand that I am REQUIRED to met with my student and his/her mentor at the initial meeting
I understand that my student will be meeting with their mentor one-on-one at least once a month
I know I MUST keep my student's medical release form updated

Student Agreement:*

I am interested in Ministry as a Profession
I will participate in the MAP program and follow the course as laid out by my mentor
I agree to meet with my mentor one-on-one at least once a month
I will share my thought with my mentor and learn as much as I can from them

To prevent spam, please tell us:

What is five plus five?*

Ministry As Profession

Registration / Agreement

Student Information

Parent / Guardian Information

Emergency Contact Information

Student and Parent Agreement