YLSS #24 (2019) Candidate and Auxie Registration - BLD Newark Youth Ministry
Online Candidate and Auxie Registration Form for YLSS #24 Sponsored by the Bukas Loob sa Diyos (BLD) Youth Ministry in Newark, NJ.

Please feel free to forward blank form (or send URL: https://docs.google.com/forms/d/e/1FAIpQLSeXjanz3BdDuM_WUCbZlOq0ZCR1QCyVqMaeoz-g-CiBPbTrXg/viewform) to other candidates and auxies.

DO NOT FORWARD link or email with your personal information or filled up form.
Registration deadline: January 31, 2019.

Thank you - God bless!

Email address *
First Name: *
(e.g. 'Jesus')
Last Name: *
(e.g. 'CHRIST')
Nickname/Preferred Name:
(e.g. 'Hesus')
Gender: *
Home Street Address: *
(e.g. 244 Central Ave)
City/Town: *
(e.g. Rahway)
State/Province: *
(e.g. New Jersey)
Zip Code: *
(e.g. 07065)
Home Phone Number:
(Landline 777-777-7777)
Cell Phone Number: *
(Landline 777-777-7777)
Age: *
Birthdate: *
MM
/
DD
/
YYYY
Medical Concerns: *
(e.g. Asthma, allergies, etc. or None)
Dietary Concerns: *
(e.g. Food allergies, Vegan, or None)
Emergency Contact Full Name: *
(First Name LAST NAME - <Relationship>)
Emergency Contact Cell/Phone Number: *
(e.g. Cell 777-777-7777)
Please check all boxes that interest you...
Are you a YLSS Candidate? *
Are you a member of any BLD District? *
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