Youth Ministry Student Registration
This form is for the youth ministry at Word Tabernacle Church. This is not a check in system. It will simply register your child to be entered into the student ministry database for ministry programming. Please contact Heather at 2529372945 or heather.scriven@wordtab.net and/or Kyle at 2523168312 or kyle.johnson@wordtab.net for more information or if you have any questions.
Child's Name
*
First Name
Last Name
Age
*
10
11
12
13
14
15
16
17
18
19
Birthdate
*
-
Month
-
Day
Year
Date
Student's Phone Number
*
-
Area Code
Phone Number
Schooling/Grade
*
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Super senior
Expected High School Graduation Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Name of Student's School
*
Does your child have any allergies, health, special needs, special information, details we may need to know?
*
Guardian 1
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Place of Employment
*
Role/Job
*
Guardian 2 Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Place of Employment
Role/Job
Emergency Contact 1: Name of person who can pick your child up other than the listed guardians.
*
First Name
Last Name
Emergency Contact 1: phone number of person who can pick your child up other than the listed guardians.
*
-
Area Code
Phone Number
Emergency Contact 2: Name of person who can pick your child up other than the listed guardians.
*
First Name
Last Name
Emergency Contact 2: phone number of person who can pick your child up other than the listed guardians.
*
-
Area Code
Phone Number
WTC May use media (photos/video/etc) of my child as needed for WTC purposes and functions.
*
Yes
No
Submit
Should be Empty: