Junior and Senior High Registration
Student Name
*
First Name
Last Name
Student Email
example@example.com
Student Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Student Grade
*
Student Birthday
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical Concerns/Allergies
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Name
*
First Name
Last Name
Parent Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
*
example@example.com
Parent Name
First Name
Last Name
Parent Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
example@example.com
I grant permission to photograph/videotape my child. Pictures may be used for publicity purposes (i.e. brochure, church website, Instagram, etc.). Children WILL NOT be identified by name on any platform.
*
Yes
No
Signature
*
Submit
Should be Empty: