High School club registration 2023-2024
This registers your student to be involved in all My Life Matters High School clubs for the 2023-2024 school year.
Sign in to Google to save your progress. Learn more
Students Name (first) *
Students Name (last) *
Grade  *
What School does the Student attend? *
Student Birthdate  *
Students Age *
Mailing Adress, city, state, zip *
Student Phone Number *
Student Contact Email *
Parent/Guardian Name *
Parent/Guardian Phone number (no spaces or hyphens) *
Parent/Guardian Email *
#1 Emergency contact name and number *
#2 Emergency contact name and number *
Allergies and Medication (list N/A if none) *
Church (if applicable) 
We offer a shuttle from PECIL, RCA, RCS, and PHS to The Warehouse for club on Thursday afternoon.  Seats are limited to first come first serve.  Signing up for the shuttle does not guarantee a spot-parents/guardians must confirm with staff via text (Will Bailey 434-942-8894 Jordan Pickrel 434-251-4300) that the student may ride the shuttle prior to attending the first time.  Once a shuttle seat is confirmed, you do not have to do anything else.  *Please do not contact the school regarding the shuttle, always contact us directly.
Clear form
Never submit passwords through Google Forms.
This form was created inside of My Life Matters. Report Abuse