2019/20 Fernie Impact Jr Youth Group Registration Form
- Please fill out one form per child.
Email address *
CHILD INFORMATION
Child's Last Name *
Your answer
Child's First Name
Your answer
Age *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
School Grade *
Your answer
Gender *
Allergies, food sensitivities or medical concerns? *
Your answer
Health Card # *
Your answer
PARENT INFO
Parents / Guardians *
Your answer
Primary Phone Number *
Your answer
Secondary Phone Number *
Your answer
EMERGENCY CONTACT INFORMATION (if parent/guardian is not available)
Name *
Your answer
Relationship to Child *
Your answer
Phone Number *
Your answer
MORE INFO
How did you hear about Impact? *
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Mountainside Community Church. Report Abuse