Rising 6th Graders - Registration & Contact Info

We look forward to welcoming you to LUMC Youth this summer! Info in this form will be used to advise you of upcoming Youth Ministry activities at the church.

STUDENTS' INFORMATION
Student's Full Name (First, Middle, and Last)
Student's Preferred Name (if other than first name)
Student's Date of Birth*
MM
/
DD
/
YYYY
School attending in Fall 2019
Home Phone
Student's Email (if different from parent's)
Street Address
Address Line 2
City
Province / State / Region
Postal Code / Zip
Country
PARENT(S)' CONTACT INFORMATION
Mom's Name
First Name
Last Name
Mom's Cell Phone
Mom's Email
Dad's Name
First Name
Last Name
Dad's Cell Phone
Dad's Email
If there are additional contacts (grandparents, step-parents, etc.), please provide any additional info here:
This information will be used to add you to the list to receive our weekly Youth Email (separate from the church email) as well as information targeted directly to our new 6th grade students and parents. Questions? Please contact Marlene Passarelli (marlene@lynnhaven.church). Thanks!