Registration Youth Wave 2019
Email address *
Name of the Student *
(First Last)
Your answer
Gender *
Date of Birth *
Your answer
T-Shirt Size *
Name of the School Currently Attending *
Your answer
Grade of the student *
Your answer
Church currently attending *
Required
If checked "other" please write the name of the church
Your answer
Please list a parent/guardian name and emergency contact number *
Name (Relationship), Phone Number (at least 2)
Your answer
Allergy to any food/medicine *
If none, write N/A
Your answer
Name health insurance provider and Policy Number *
Your answer
Signature of the parent/Guardian *
I understand that by checking the box below, I agree and give my signature to all statements above
Required
Date of the signature *
MM/DD/YYYY
Your answer
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