Bergvliet Methodist Youth Church Registration Form

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Email *

Mother/Legal Guardian Surname

Mother/Legal Guardian Name

Mother/Legal Guardian Email

Mother/Legal Guardian Address

Mother/Legal Guardian Phone number

Father/Legal Guardian Surname

Father/Legal Guardian Name

Father/Legal Guardian Email

Father/Legal Guardian Address

Father/Legal Guardian Phone Number

First Child

Child's Surname *

Child's Name *

Child's Date of Birth *

YYYY

Child's School *

Child's Grade *

Allergies

Important medical information and medication

Bergvliet Methodist Church Social Media Consent *

I agree to the use by Bergvliet Methodist Church of photos and videos of my child/ren participating in church activities. Selection of the photographs to be used, shall be at the discretion of Bergvliet Methodist Church.

I do not agree to the use by Bergvliet Methodist Church of photos and videos of my child/ren.

Required

Our family is a member of Bergvliet Methodist Church *

Yes

We would like to become members

Second Child

Child's Surname

Child's Name

Child's Date of Birth

YYYY

Child's School

Child's Grade

Allergies

Important medical information and medication

Third Child

Child's Surname

Child's Name

Child's Date of Birth

YYYY

Child's School

Child's Grade

Allergies

Important Medical Information and Medicine

Fourth Child

Child's Surname

Child's Name

Child's Date of Birth

YYYY

Child's School

Child's Grade

Allergies

Important Medical Information and Medicine

Submit

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