Youth Revival 2023 Individual Registration

Youth Name *

First

Last

Parent/Guardian Name *

First

Last

Address *

(Street address, city, state, zip code)

Mailing Address (if different)

(Street address, city, state, zip code)

Home Phone

Work Phone

Cell Phone

Email Address

Birth Date *

School Grade *

(Last grade completed in school)

Medical Information

Medical or other information we need to know. (Please include food allergies)

Emergency 1 Contact Name

Relationship

Phone Number

Emergency Contact 2 Name

Relationship

Phone Number

Do you attend Sunday school?

Where?

Are you visiting our church?

As a guest of whom?

May we have your permission to photograph you? *

May we have permission to use your photograph for the purpose of promotion? *