3:16 Kingdom 2026 Registration Form

3:16 Kingdom 2026 Registration Form

Youth Organization of Life Changers Church & Ministries Inc.
Information of Youth
Name

First NameM.I.
Last Name
Birth Date

MonthDayYear
My Child is currently blanks years old
The Youths Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Information of guardian/parent
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact 1
In the event of an emergency, please contact:
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Medical Information
Please list any of the following: Current allergies, food allergies, or chronic health concerns.
Please list the following: Current medications
Please list the following: Child's Physician and Physician's Phone #
Please Read and answer the following questions carefully as they are in regards to your child's health. Please speak to Youth Pastors Tiffany Reed and Marcos Bejarano regarding an medications or special needs your child may have. THIS INFORMATION WILL REMAIN CONFIDENTIAL. IT WILL STAY BETWEEN THE PARTIES PRESENT. .,............................................................................................................... Does your child have any behavioral issues that we need to be aware of? Please explain below
Does your child need to be accompanied on trips? ( Y or N )
Parent/Guardian Signature (type parent full name)
Should be Empty:

3:16 Kingdom 2026 Registration Form

Information of Youth

Information of guardian/parent

Medical Information