Registration form
Youngsville Free Methodist Church Lighthouse Teens
Youth Leader:  Jessie Green
Contact:  jessie@ybfree.org
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Email *
Student Information
Name *
Grade *
Date of Birth *
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DD
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Address *
City, State, Zip *
Cell Phone/Home Phone *
Email If Available *
Allergies or Medical Concerns *
Parent(s)/Legal Guardian(s) *
Parent Email *
Would parent like to be on email list *
Required
Emergency Contact Information
Emergency Contact Name 1 *
Relationship to Student *
Phone *
Emergency Contact Name 2
Relationship to Student
Phone
Student Oath
As a member of Youngsville Free Methodist Church Lighthouse Youth Group, I promise to be respectful to all in attendance, to be responsible for any guests I bring along, and to remain with the group at all times.  I understand that I am an important part of this youth group and that my active participation is a way of showing I care about and respect all those involved.  My parent(s) and I understand these guidelines and realize that, if violated, actions deemed necessary by the Youth Pastor will be taken, which may include parental contact.
Student Signature/Date *
Parent Signature/Date* *
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