NMBC Youth Registration

Please fill out this form and click submit.

Please carefully fill out information regarding your family and your student (6th-12th grade)! We want to make sure we can provide the best care for your family and this information assures that our ministry team can partner with you to point your child to Jesus!

Student Name

*

Birthdate

*

Gender

*

Please select all that apply.

Male Female

Grade

*

Please select one option.

6th 7th 8th 9th 10th 11th 12th

Email

Phone

Address

*

Allergy info

Medical info

*

1 Parent/Guardian Full Name

*

1 Parent/Guardian Relationship to Student

*

Please select all that apply.

Father Mother Grandparent Other

1 Parent/Guardian Email

*

This address will receive a confirmation email

1 Parent/Guardian Cell Phone

*

2 Parent/Guardian Full Name

2 Parent/Guardian Relationship to Student

Please select all that apply.

Father Mother Grandparent Other

2 Parent/Guardian Email

2 Parent/Guardian Relationship to Student

Please select all that apply.

Father Mother Grandparent Other

2 Parent/Guardian Cell Phone

Please Share Any Additional Info About Your Teen

I am interested learning more about

*

Please select all that apply.

Jesus Baptism Youth Group Sunday Bible Study Service Opportunities Small Groups Counseling

Description

Please fill out this form and click submit.

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