Course Registration Form

Progressive Dinner Form
Teens Name*

First NameMiddle NameLast Name
Any Medical Needs: Be Specific!
Grade*

6th7th8th9th10th11th12th
Parent/Emergency Contact*
Parent/Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Who can pick teen up?
blanks*
By signing: I agree to allow my teen listed above to attend the Progressive Dinner on June 5th 2026 with the Liberty Baptist Church Youth. *
Should be Empty:

Progressive Dinner Form