MAD4Christ Glory Baptist Church Youth Group
Registration and Health Information Form and Release of Claims, Waiver of Liability and Indemnification Agreement Grades 7th-12th.

Effective September 2020 to September 2021
Student Name *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Student's Email *
Student's Cell Number *
Home Phone *
Household Email
Father/Guardian Name
Father/Guardian Email
Father/Guardian Cell
Mother/Guardian Name
Mother/Guardian Email
Mother/Guardian Cell
Other Phone Numbers (Work etc in case of emergency)
Name of School *
Does Student have Facebook *
Current Grade of Student *
Student lives with? *
Emergency Contact (outside of immediate family) *
Emergency Contact Relationship to Student *
Emergency Contact Best Phone # *
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