Student Name *

First Name

Last Name

Returning Launch Pad Student? *

Yes

No

For College Credit? *

Yes

No

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student's Phone *

(###)

###

####

Parent Name *

First Name

Last Name

Cell Phone

(###)

###

####

Home Phone

(###)

###

####

Contact Preference *

Phone

Email

Text

Emergency Contact: *

First Name

Last Name

Emergency Contact Phone: *

(###)

###

####

*

As parent/legal guardian, I give permission for my student to attend a Launch Pad class.

*

My student and I have read and agree to the: Policies in the Parent-Student Handbook.

The Parent/Student handbook is located under the Parents tab under resources.

*

By checking this box, I acknowledge Launch Ministries, Inc.’s Policy Regarding Use of Images and Statements.

Date *

MM

DD

YYYY

How did you hear

How did you hear about Launch Pad?

Friend

Church/Youth Group

School

Event

Other (Please share with us how you heard about Launch pad)