J2A Youth Group Registration 2021-2022

Youth Group Registration 2021-2022

Please fill out one form per youth. Weekly sessions will be held on Sundays at 6pm at St. James the Less Church in Ashland.
Youth Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Church
School
Grade Level
Does the child have any allergies?
Does the child have any medical conditions that we should be aware of?
YESNOContact me with additional information
Parent/Guardian Information
Name

First NameLast Name
Cell phone number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Photo Release
The North Richmond Region of the Episcopal Diocese of Virginia and/or its constituent churches (St. James the Less, Epiphany Lakeside, Our Creator Mechanicsville, Immanuel Old Church, Emmanuel Brook Hill, Church of Our Savior, Fork Church, All Souls Mechanicsville, Calvary Chapel, St. Paul's Hanover and All Souls Mechanicsville) have my permission to use my or my child's photograph publicly to promote their ministry. I understand that the images may be used in print publications, online publications, presentations, websites and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.
Parent/Guardian Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Youth Group Registration 2021-2022