Registration for Youth Ministry

ABC Youth Ministry Registration
(Please fill out a separate registration form for each teen)

* Indicates required field

Parent's Name *

First

Last

Primary Contact Phone Number *

Additional Phone Number *

Email *

DEROS (enter "N/A" if not military) *

Teen's Name *

First

Last

DOB (MM/DD/YYYY) *

Allergies or Special Information (enter "N/A" if none) *

Age Group *

Does your teen have an inhaler? *

Yes No

Do we have your permission to administer your teen's inhaler if needed? *

Yes No N/A

Does your teen have an Epipen? *

Yes No

Do we have your permission to administer your teen's Epipen if needed? *

Yes No N/A

Is there anything you would like us to know about your teen? *

Can we take your teen's picture to use in classroom displays? *

Yes No

Can we use your teen's picture in on-line media (website, social media, newsletter)? We will not use teen's name. *

Yes No

Submit