The Upper Room Registration Form (FY 26)
PLEASE NOTE: To be completed for EACH participant.  If you are a parent or guardian completing this for your child, use the child's information to complete this form. Please complete all questions.
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Last Name *
First Name *
Preferred Name
Date of Birth (please use 4 digits for the birth year) *
MM
/
DD
/
YYYY
Street Address *
City/Town *
If you chose "OTHER, NOT IN NH", please indicate your City/Town.
State *
Zip Code *
Email Address
Phone Number (Please use area code, for example 603-555-5555)
If you are a minor, please indicate the name of your custodial parent/guardian.
If you are a minor, please indicate the phone number of your custodial parent/guardian. (Please use area code, for example: 603-555-5555)
If you are a minor, please indicate the email of your custodial parent/guardian.
What is your sex?
Clear selection
Which race/ethnicity best describes you? (Please choose all that apply.)
Is your primary language English?
Clear selection
If 18 years or older, are you a US Veteran or an active US Military Member?
Clear selection
If under 18, is your parent/guardian a US Veteran or an active US Military Member?
Clear selection
Which of the following best describes your current relationship status?
Clear selection
Do you need assistance with:
Clear selection
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