Amplify (5th & 6th grade) Registration Form

PreTeen Information

First Name

Gender

Boy Girl

Age

Grade

Date of Birth

Mailing Address

Primary Phone

Allergies, medical conditions, or special needs

Do we have permission to video/photograph child?

Yes No

Parent's Information

Primary Contact Email

This address will receive a confirmation email

Name of Parent(s)/Caregiver(s) and Phone #

Home Church

In Case of Emergency

Contact

Phone

Relationship to child

Description

Please fill out this form and click submit.