Register Online for
Teen Life Support

I want to register my teen for:	Confirmation Hot Girls True Guys
*Teen's First Name:
*Teen's Last Name:
*Teen's Gender:	Male Female
Teen's Birthdate:
Teen's Baptism Birthdate:
Street Address:
City:
State:
Zip:
Home/Evening Phone: (if you do not have a home phone, please type in your cell phone number here.)
Cell phone:
Grade in Fall of 2006	7th Grade 8th Grade 9-12th Grade (please choose one grade)
E-Mail Address
Parent or Guardian #1 (First & Last Name):
Work phone #1:
Parent/Guardian # 2 (First & Last Name):
Work phone #2:
Allergies, medical conditions, or other information we need to know:
	I give my permission and authorize the staff to secure a doctor to provide any necessary EMERGENCY MEDICAL CARE if needed.
Date:

*These fields are required.