Registration (6th - 12th G...

Youth Ministry Registration Form (6th - 12th Grade)

Youth's First Name

Name Goes By

Youth's Last Name

List any known allergies / food allergies your youth may have:

List any medical conditions or physical limitations your youth may have:

Birthday

Age

Gender

Grade

School

Youth's Address

City

Zip Code

Youth's Phone #

Youth's Email Address

Mother/Guardian Name

Email Address

Mother/Guardian Phone #

Father/Guardian Name

Email Address

Father/Guardian Phone #

Are there any learning or educational concerns that would help us serve your youth better?

My youth has permission to attend Wednesday Night BREAKOUT.

I give permission for the youth leaders to contact my youth by phone, text, or email.

I give permission for my youth to be photographed for possible use in church media and printed materials.

Please do not photograph my youth

By typing your name you are electronically signing this form.

Date: