Referral Form

Bethany loves to connect with young souls in their exploration of a bright future in service to our Lord. We think you know of a young soul who could benefit from being a Bethany student, artist, athlete, or leader.
The student you refer can opt out of messages anytime, so there is no risk.
Please provide as much information on the student as possible. We want to connect with them in a meaningful way.

STUDENT PERSONAL INFORMATION:

*-required

First Name

Last Name

Email Address

Birthdate

Gender:

Female

Male

CONTACT INFORMATION

Home phone:

Cell Phone:

Text me

Mailing Address

Country

Street

City

Region

Postal Code

ENROLLMENT DETAILS

Student will be attending as a:

High School Grad Year:

Current Grade in School?

High School Name:

School Ceeb:

INFORMATION YOU WOULD LIKE US TO SEND

General Campus:

Bethany Activities:

YOUR INFORMATION

First Name

Last Name

Your Email address

How do you know this student and what encouraged you to refer them to Bethany?

Additional notes/information you would like to share:

Referral Form

*-required

Resources

Services

Contact