High School Youth Group Registration

High School Youth Group Registration

9th-12th Grade
Youth Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / 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 NameLast Name
Mother's Name

First NameLast 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 Form Liability Waiver 3. J-I Form Field Trip Form (please save to your device and upload below)
J-H Liability Waiver

J-I Youth Activity Release Form
File Upload

Cancelof
Should be Empty:

Parent/Guardian Information