2017-2018 High School Youth Group Registration
Youth's Name (First and Last) *
Your answer
Youth's Preferred Name/Nickname *
Your answer
Youth's Address *
Your answer
Youth's Birthday *
MM
/
DD
/
YYYY
Youth's Email *
Your answer
Youth's Cell Phone # *
Your answer
School Youth Attending *
Your answer
Youth's Grade in 2016-2017 *
Your answer
Youth's On Facebook? (check one) *
Home Phone # *
Your answer
How should we contact youth? (Check best ways) *
Required
Parent/Guardian Name (1) *
Your answer
Parent/Guardian Cell Phone # (1) *
Your answer
Parent/Guardian Email (1) *
Your answer
Parent/Guardian Name (2)
Your answer
Parent/Guardian Cell Phone # (2)
Your answer
Parent/Guardian Email (2)
Your answer
Emergency name if parents can not be reached *
Your answer
Emergency Contact # (if parents can not be reached) *
Your answer
Youth's Doctor *
Your answer
Doctor's Phone # *
Your answer
Insurance Company *
Your answer
Policy # *
Your answer
Insurance phone # *
Your answer
Health concerns, physical limitations and/or allergies
Your answer
Would you be willing to help with special Youth Group needs such as:
Number of passengers your car holds
Your answer
In order to share the good news of the ministries of The Dover Church, we sometimes take photos of youth for use on bulletin boards, in our newsletter and on our website. When published on our website we DO NOT include any identifying information (name, address, etc.) about the youth along with the photo. Please indicate if you do or do not authorize the use and reproduction of your youth's photo(s) by The Dover Church. *
Required
Adult signature for photo authorization *
Your answer
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