2024 Youth Conference

3:16 Squad 2025 Youth Conference

Presents: A Journey of Transformation "CHANGE STARTS WITHIN YOU" Eph. 4:21-24
STUDENT INFORMATION
Name*

First NameLast Name
Number
Birth Date *

MonthDayYear
Date
Gender*
Grade completed by *
Home Church (if any)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
EMERGENCY CONTACTS
Please list the first and last names and phone numbers off ALL adults who are allowed to pick up this child. The child will only be released to these people.
Primary Guardian*

First NameLast Name
Relationship to child*
Phone Number*
Alternate Guardian #1*

First NameLast Name
Relationship to child*
Phone Number*
Alternate Guardian #2

First NameLast Name
Relationship to child
Phone Number
Medical Information
Please list all allergies -- or type "none" if there are none*
Does your child carry an epi-pen? (please note: if yes, it is the responsibilty of the child's guardian to ensure the child has the epi-pen at every drop off and pick up)*

YesNo
Please list all medical concerns -- or type "none" if there are none*
Photo Waiver
I give First Baptist Church permission to take my child's picture and use the images of their social media platforms

Yes, I give permission.No, I do not give permission.
Liability Waiver

I agree to hold First Baptist Church entirely FREE from any liability, including any injuries incurred, regardless of whether injuries are caused by negligence, including Covid-19.
For any questions or concerns, contact Victoria Canady at (478)550-4784 or Lady Aisha Scott at (706)315-8976.
By submitting this form, I ackowledge I have read and understand the above information.
Signature

Powered by Jotform SignClear
Should be Empty:

3:16 Squad 2025 Youth Conference

Medical Information

Photo Waiver

Liability Waiver