Youth Group Registration Form
Youth Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your home community or band? (If known)
MB Health #
Does you have any allergies?
Do you have any medical conditions that we should be aware of?
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship
Signature and Consent
Do you want to be photographed and put on our social media? Yes or No (if yes please add signature)
Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: