Course Registration Form

POP Confirmation Registration Form

Prince of Peace Confirmation 2022 - 2023
1) Student Name

First Name Middle Name Last Name
2) Prefers to be called
Nick Name or Preference
3) Student E-mail
example@example.com
4) Student's Mobile Number
Please enter a valid phone number.
5) Student's School Grade

Upcoming 7th Grader Upcoming 8th Grader Upcoming 9th Grader
6) Birth Date

Month Day Year
7) Date of Baptism

Month Day Year
8) Student's Primary address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
9) Parent(s) Name(s)

First Name Middle Name Last Name
9a) Parent(s) Name(s)

First Name Middle Name Last Name
10) Parent's Mobile Number
10a)Parent's Phone Number
Abilities & Challenges
11) Student has the following gifts / abilities (e.g.: public speaking, dance, sports, singing, playing an instrument, intelligence, etc.)
12) Student is involved in the following school and / or community activities (e.g.: soccer, hockey, choir, drama, band, etc.)
13) Student has behavioral difficulty *:

Yes No
13a) * If you selected Yes, please explain:
14) Student has a special need / concern *:

Yes No
14a) * If you selected Yes, please explain:
* All information of this nature is confidential, but if you would rather discuss any issue personally, please contact Pastor Brett 856-470-8793 or email: pastorbrett@popmarlton.org
Parental Involvement
15) I can drive for a carpool:

Yes No
15a) * If you selected 'Yes', how many teens and what neighborhood?:
16) I'm willing to be a Guide.

Yes I need more information.
17) I'm willing to be a Guide.

Yes I need more information.
18) I'm willing to help drive / chaperone events.

Yes I need more information.
19) I have questions regarding the Confirmation Program.

Yes
20) I would like Pastor Brett to discuss Confirmation with my family.

Yes
Any questions or concerns can be directed to Pastor Brett (pastorbrett@popmarlton.org)
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POP Confirmation Registration Form