Camrose Junior Youth Program Registration
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Email
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Junior Youth Name
*
First Name
Last Name
Junior Youth Birthday
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Junior Youth Phone (not required)
Please enter a valid phone number.
Format: (000) 000-0000.
Does the participant have any allergies or medical conditions of which the organizers should be aware?
*
Photographs and videos may be taken of Program classes, events, and activities in which the participant participates. Do you give permission for these images to be used as non-commercial promotional material for the Junior Youth Spiritual Empowerment Program?
*
I give permission
I do not give permission
Parent/Guardian’s Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: