Youth and Family Ministries Registration

Please fill out this form and click submit.

Student Information

Students Name

*

Student Phone

Student Email

Primary Address

*

Student Birth Date

*

School Name

Current Grade Level

*

Please select one option.

Pre-School Pre-K Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th

Parent/Guardian Information

Parent/Guardian 1 - Full Name

*

Parent/Guardian 1 - Phone

*

Parent/Guardian 1 - Email

*

This address will receive a confirmation email

Parent/Guardian 1 - Can pickup

*

Please select one option.

Yes No

Parent/Guardian 2 - Full Name

Parent/Guardian 2 - Phone Number

Parent/Guardian 2 - Email

Parent/Guardian 2 can pick up

*

Please select one option.

Yes No

Student Lives With

*

Please select one option.

Parent/Guardian 1 Parent/Guardian 2 Both Parents/Guardians Others

Emergency Contact Information

Emergency Contacts can also pick up student from events

Emergency Contact 1 - Name

*

Emergency Contact 1 - Phone

*

Emergency Contact 2 - Name

Emergency Contact 2 - Phone

Other Emergency contacts (please provide full name and phone number)

Medical Information

Allergies

*

Health concerns

*

Current Medications

*

Student's Needs

Special Needs

Special Interests/Activities/Sports

Other Religious Experiences

What talents does your teen have that they don't see in themselves

Does your student have a part-time job (teens)

Photo Permission

May we share images of your child as part of group activities to the church website and social media pages

*

Please select one option.

Yes No

Description

Please fill out this form and click submit.

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