SHINE 2026 Connect Card

SHINE// A Jesus Church Connect Card

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Adult 1

First NameLast Name
Adult 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Adult 1 Email
example@example.com
Adult 1 Birthday

MonthDayYear
Date
Adult 2 Name

First NameLast Name
Adult 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Adult 2 Email
example@example.com
Adult 2 Birthdate

MonthDayYear
Date
Address of Family

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Children's and Youth info below Please fill out for your children that are under 18 and live in the home with you.
Child/Youth

First NameLast Name
Gender
Phone Number of Parent
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate

MonthDayYear
Date
Grade of Child/ Youth
Do they have any allergies/ medical conditions that we should know about?
Child/Youth

First NameLast Name
Gender
Phone Number of Parent
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate

MonthDayYear
Date
Grade of Child/ Youth
Do they have any allergies/ medical conditions that we should know about?
Child/Youth

First NameLast Name
Gender
Phone Number of Parent
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate

MonthDayYear
Date
Grade of Child/ Youth
Do they have any allergies/ medical conditions that we should know about?
Child/Youth

First NameLast Name
Gender
Phone Number of Parent
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate

MonthDayYear
Date
Grade of Child/ Youth
Do they have any allergies/ medical conditions that we should know about?
Should be Empty:

SHINE// A Jesus Church Connect Card

Children's and Youth info below Please fill out for your children that are under 18 and live in the home with you.