District Blitz Youth Conference Registration

Student Registration Form

Fill out the form carefully for registration
Student Name

First Name Middle Name Last Name
Birth Date

Month Day Year
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent E-mail
Parent Phone Number

Area Code Phone Number
Emergency Contact

Area Code Phone Number
Additional Comments/ PLEASE LIST STUDENT ALLERGIES HERE
Payment Method:

Check payable to Rock Hill Church ($65.00) Online via Paypal
If you selected to pay online you will be redirected to PayPal to complete your registration upon hitting the submit button below.
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District Blitz 2020 $ 65.00

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Student Registration Form