My Life Matters Registration for Christian Enrichment Clubs and the Warehouse Youth Center for 2023-2024
Comuníquese con nuestra oficina para solicitar este formulario en español.
mylifemattersoffice@gmail.com
80 Danwin Lane, Roxboro, NC. 27573

Please fill out the form once for each student you are registering.

Club Start Times and Dates:

Tuesday Sept. 12th, 3:00 PM - 5:15 PM
-Stories Creek Elementary
-North End Elementary
-Bethel Hill Charter School
-Helena Elementary

Thursday Sept. 14th, 3:00 PM - 5:15 PM
-South Elementary
-Woodland Elementary
-Oak Lane Elementary
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Email *
Please fill out the form once for each student you are registering
First Name (Student's) *
Last Name (Student's) *
School *
Student's Teacher *
Age (Student's) *
Grade the Fall of 2023 (Student's) *
Small Group (Office Use Only)
Gender (Student's) *
Date of Birth *
MM
/
DD
/
YYYY
Student's Street Address *
City, State, Zip *
Student's mailing Address if different *
Student's Church (If applicable)
Parent/Guardian Name *
Phone (Parent/Guardian) xxx-xxx-xxxx *
2nd Phone (optional)
List additional Emergency Contacts and People Authorized to pick-up this student. (Include other family members)

If someone is not listed they will not be allowed to pick up.
Pickup/Contact #1 - Name and Phone
Pickup/Contact #2 - Name and Phone
Pickup/Contact #3 - Name and Phone
Pickup/Contact #4 - Name and Phone
Pickup/Contact #5 - Name and Phone
Is this student allowed to walk home? *
Allergies/Medications/Health Notes
Does your child have any special needs that we should be made aware of to better serve them?
Counseling Permission
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