Youth Confirmation Registration
Name

First
Last
Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Phone Number *

###		-
###		-
####
Cell Phone Number

###		-
###		-
####
Email
Birth Date *

MM		/
DD		/
YYYY
Father's Name *

First
Last
Mother's Name *

First
Last
Name of school child attends *
List any physical, emotional, or learning disabilities the instructor should be aware of.
By checking the box, we certify and accept the requirement that the student is expected to attend worship at least 50% of the time. *
 I agree 
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