Youth Information
Name
First Name
Middle Name
Last Name
Suffix
Preferred Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Please Select
Male
Female
Name of School
Grade
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Parent / Guardian Information
Name
First Name
Middle Name
Last Name
Suffix
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
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Emergency Contact Information
Name
First Name
Middle Name
Last Name
Suffix
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
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Photo Release
The Central Baptist Church may periodically publish and use photos and videos from U18 Youth Connection activities on the church's website or in other publications. It is the Church's policy that names or other identifying information are not published with photos or videos.Please check one box below.
Yes, you can use pictures and videos of my child. I hereby grant The Central Baptist Church, the permission to use my child's likeness in photographs, videos, and other media in any and all of its publications, including bulletin boards and website entries. I waive any right to royalties or other compensation arising or related to the use of photographs or videos.
No, please do not print or publish photos of videos of my child online or in church-related publications.
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