Level Up Registration

Level Up Registration

Teens Ages 12 -16 Years Old
Teen Details
Teen #1 Name*

First NameLast Name
Teen Cell Phone Number
Please enter a valid phone number.
Teen Birthday

MonthDayYear
Date
Upload Current Photo of Teen:

This photo will NOT be used on any social media platform. This is to help the Ministry's staff to keep account of all teens and connect with them.
Cancelof
T-Shirt Size

X-SmallSmallLargeXL2XL
Is there another Teen to sign up?
Teen #2 Name

First NameLast Name
Teen Cell Phone Number
Please enter a valid phone number.
Teen Birthday

MonthDayYear
Date
Upload Current Photo of Teen:

This photo will NOT be used on any social media platform. This is to help the Ministry's staff to keep account of all teens and connect with them.
Cancelof
T-Shirt Size

X-SmallSmallLargeXL2XL
Is there another Teen to sign up?
Teen #3 Name

First NameLast Name
Teen Cell Phone Number
Please enter a valid phone number.
Teen Birthday

MonthDayYear
Date
Upload Current Photo of Teen:

This photo will NOT be used on any social media platform. This is to help the Ministry's staff to keep account of all teens and connect with them.
Cancelof
T-Shirt Size

X-SmallSmallLargeXL2XL
Parent/Guardian Information
Parent/Guadian Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Teen(s)*
Medical Information
Primary Care Physician

First NameLast Name
Physician's Phone Number
Please enter a valid phone number.
Does the teen(s) have any allergies (food, medication, environmental)?*
Please name the teen(s) and the allergies associated with them.
Does the teen(s) have any chronic conditions or illnesses (e.g. asthma, diabetes, eplepsy)?*
Please name the teen(s) and the chronic conditions associated with them.
Do the teen(s) currently take any medications?*
Please name the teen(s) and the medications associated with them.
If the teen(s) need to take medication during meetings, please state instructions so we can ensure the best safety of the teen(s).
Has the teen(s) recieved the following vaccinations? Please check the box for YES.*

TetanusMeasles, Mumps, Rubella (MMR)Chickenpox (Varicellea)Hepatitis BOther
Please list any other vaccinations we need to know about.
Dietary Restrictions
Do the teen(s) have any dietary restrictions?*
Please name the teen(s) and their dietary restrictions.
Emergency Authorization
In the event of an emergency, I hereby authorize the ministry staff to ensure medical treatment for the teen(s), including transportation to the nearest medical facility if necessary. I understand that every effort will be made to contact me or the emergency contact provided before such action is taken.*
Permissions
I give permission for my teen(s) to participate in all social activities. I will speak with Lisa Duncan (Youth Director) if there is an issue with any of the following activities.*
I give permission for my teen(s) photo to be taken and used for the ministry's social promotional materials. *
Please note anything not mentioned in the form about the teen(s). We want to take care and ensure the BEST safety for the group.
Payment

My Products*

Level Up Registration - Year 2026 Product Image

Level Up Registration - Year 2026Level Up is a supportive space for teens. We will get together in the community for practical workshops, impactful volunteer projects, and exciting job shadow opportunities. We are building skilled and confidence teens need to shape their own successful futures.

$50.00 Quantity

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Total

$0.00

Credit Card

Please sign for authorization and all information above is true.*

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Level Up Registration

Teen Details

Parent/Guardian Information

Emergency Contact Information

Medical Information

Dietary Restrictions

Emergency Authorization

Permissions

Payment

Credit Card