Immanuel BJJ Registration (Ages 12-17)
Fall 2024 session, starting Sunday September 22, 2024
Parent / Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Parent / Guardian Phone Number
*
Student Name
*
First Name
Last Name
Student Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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Day
Please select a year
2013
2012
2011
2010
2009
2008
2007
Year
Student Gender
Please Select
Male
Female
N/A
Does your child have any medical, physical, emotional or behavioral concerns or limitations that our Leaders should be aware of? If yes, please describe below:
Emergency Contact Name & Phone Number
We occasionally take videos and photographs of our programs for promotional purposes. Do you consent to having your child's photo used on our social media platforms, website, and/or print media?
*
Yes
No
I understand that Immanuel Baptist Church makes every effort to maintain a healthy and safe environment. However, I know there are still risks associated with attending group activities, and sometimes unforeseen circumstances. I will not hold Immanuel, its staff or volunteers, responsible in the event my child experiences sickness or injury as a result of participating in the Immanuel BJJ program.
*
I agree to the above statement.
Would you like to receive email updates about Immanuel Church and Kids Events?
*
Yes
No
Are you currently attending a church? If yes, please specify which one:
*
Submit
Should be Empty: