RISE Young Adult Ministry
2024-2025
Registration
Personal Information
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
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Gender
*
Please Select
Male
Female
Please list any medical conditions, allergies, or special needs for this teen
*
I give permission to The Holy Name of Jesus to publish photos of my child in church related social media.
*
Please Select
Yes
No
Email
Cell Phone
-
Area Code
Phone Number
Emergency Contact (If Parent/Guardian cannot be reached)
*
Relationship to Student
*
Emergency Phone Number
*
-
Area Code
Phone Number
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