Faith Communities

Religious/Spiritual Preference Form

Student Information

First name

Middle name (Optional)

Last name

Nickname (Optional)

Address (Optional)

City (Optional)

State (Optional)

Zip/Postal Code (Optional)

Country (Optional)

Date of birth (Optional)

Home phone (Optional)

Cell phone (Optional)

Preferred email

Rochester email (Optional)

Parent One Information

Name (Optional)

Email (Optional)

Address (Optional)

City (Optional)

State (Optional)

Zip/Postal Code (Optional)

Parent Two Information

Name (Optional)

Email (Optional)

Address (Optional)

City (Optional)

State (Optional)

Zip/Postal Code (Optional)

Student Preferences

If you selected "other" interests above please describe: (Optional)

If you selected "Protestant" or "other" in the religious affiliations above please describe: (Optional)

Please provide place of worship (parish/synagogue/mosque/etc.) if applicable:

Name (Optional)

Address (Optional)

City (Optional)

State (Optional)

Zip/Postal Code (Optional)

Comments/Suggestions/Needs (Optional)