Youth Registration Form

Forms

UPCOMING
EVENTS

Youth Registration Form

Youth's First Name

Youth's Last Name

Parent / Guardian

Address

Address 1

Address 2

City

State/Province

Zip/Postal

Home Phone

Cell Phone

Email Address

Age Information

This information is needed in order to place your child in the appropriate age groups.

Date of Birth

Age

Last Grade Completed

Health Information

Any known allergies?

Yes

Please list/describe your child's allergies

Please note: Any prescribed medications (i.e. insulin) cannot be administered by members of Antioch Missionary Baptist Church without explicit written permission from the guardian

Do you give permission to contact medical personnel in the case of an emergency?

Yes

Emergency Contacts

First & Last Name

Relationship to Child

Phone Number

Add Remove

Your signature gives permission for the above-named child to remain with the volunteer staff of Antioch Missionary Baptist Church, within the church, during the time designated.

Signature

Clear

Date

If you are human, leave this field blank.

Forms

UPCOMING
EVENTS