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2016-17 Emmaus Youth Registration
Please complete this form to register for youth programming at Emmaus Church for the 2016-17 school year. The information you provide will be very helpful to us in facilitating our planning and communication. Thank you!
Student Name
Your answer
Please select which youth programs you plan to attend at Emmaus.
Grade for the 2016-17 School Year
School
Birthday
Your answer
Student Cell Phone Number
Your answer
Student Email Address
Your answer
Student Instagram Username
Your answer
Student Facebook Username
Your answer
Please list any activities, hobbies, or sports that you are involved in.
Your answer
Home Phone Number
Your answer
Home Address
Your answer
Name of Parent/Guardian #1
Your answer
Parent/Guardian #1 Cell Phone Number
Your answer
Parent/Guardian #1 Email Address
Your answer
Parent/Guardian #1 Facebook Username
Your answer
Name of Parent/Guardian #2
Your answer
Parent/Guardian #2 Cell Phone Number
Your answer
Parent/Guardian #2 Email Address
Your answer
Parent/Guardian #2 Facebook Username
Your answer
Please list any allergies, medical conditions, or special needs of which we should be aware.
Your answer
Please indicate your insurance provider and ID number.
Your answer
Please indicate your home church.
Please list any questions or comments you have.
Your answer
Thank you for completing this registration form!
We are excited to have you join us for programming at Emmaus this year!
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