Resurrection Youth Program Registration Form 2019/2020
Program Start Dates:
Kids Alive [Kindergarten - Grade 5 ] - October 27th @ 2:00 - 3:30 pm
Jump [Grade 6 - 8 ] - October 21st @ 7:00 - 9:00 pm
Higher [ Grade 9 - 12] - October 28th @ 7:00 - 9:00 pm
Email address *
Participant Name (First and Last) *
Your answer
Grade *
Your answer
Program *
Required
Participant Email Address *
Your answer
Participant Cell Phone *
Your answer
Parent(s) / Guardian(s) Names *
Your answer
Home Phone *
Your answer
Parent(s) / Guardian(s) Phone Number *
Your answer
Parent(s) / Guardian(s) Email Address *
Your answer
Emergency Contact (If parent of guardian cannot be reached) *
Your answer
Emergency Contact Phome Number *
Your answer
List of any Medical Concerns or Allergies
Your answer
Does the participant carry an epipen? *
If "yes", where do they carry it?
Your answer
List of any other concerns that would be applicable
Your answer
I give permission for the above mentioned name to attend any youth program events at Resurrection Parish and I take responsibility for him or her. I understand that she/he is expected to participate in the above stated activity. *
Required
I will be picking up my child. *
If not, my child will be picked up by:
Your answer
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