SHIFT

Registration Forms must be submitted with the registration fee, of $50, by August 28th 2022 to:
Theo Cox, 3290 N Mount Juliet Rd, Mount Juliet TN 37122 (Checks made out to East TN District NDI)
Phone: (615)-450-3763 Email: Theo@mjnaz.org
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Ex. 11-10-1992
Name of Church
Ex. Mount Juliet Church of the Nazarene
Students T-shirt Size. (Adult Sizes)

XSSMLXL2XL3XL
Parent/Legal Guardian Information
Father’s Name (or Legal Guardian)

First NameLast Name
Email
example@example.com
Address
City
State
Zip
Home Phone #
Please enter a valid phone number.
Work Phone #
Please enter a valid phone number.
Cellphone #
Please enter a valid phone number.
Mother’s Name (or Legal Guardian):

First NameLast Name
Email
example@example.com
Address
City
State
Zip
Home Phone #
Please enter a valid phone number.
Work Phone #
Please enter a valid phone number.
Cellphone #
Please enter a valid phone number.
Please note anything you feel our staff needs to know about working with your preteen/preteens.
Parent Signature:

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