Middle School Youth Group Registration
6th-8th Grade
Youth Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
Grade Level
Insurance Provider Name
Medical Insurance #
Does the child have any allergies?
Does the child have any medical conditions that we should be aware of?
Parent/Guardian Information
Father's Name
First Name
Last Name
Mother's Name
First Name
Last Name
Father's Phone Number
Please enter a valid phone number.
Mother's Phone Number
Please enter a valid phone number.
Required Documents
1. Copy of Health Insurance 2. J-h Liability Waiver 3. J-i Youth Activity Release (please save forms to your device and upload below)
J-h Liability Waiver
J-i Youth Activity Release Form
File Upload
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