Saturday, May 27, 2017
Name of Youth to be Registered:
Phone:
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Address:
E-mail:
Parent/Guardian's Name:
Parent/Guardian's Cell or Work Number
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Parent or Guardian's Email:
Parent or Guardian's Home Phone:
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Youth's Age:
Youth's Grade in January 2017:
Member of UBC?:
If no, Name of Church Home:
Emergency contact:
Emergency contact's phone:
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Please list any allergies or other medical conditions:
Family Doctor's Name:
Family Doctor's Phone:
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Sibling 1 attending name and age:
Sibling 2 attending name and age:
Sibling 3 attending name and age:
Sibling 4 attending name and age:
Will youth need transportation?:
Best time to Call:
Person who will drop off:
Person who will pick up:
Youth will attend (check all that apply):
Word Verification: