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Xtreme Registration 11-12

Thanks for your interest in Door Creek Church High School Ministry - Xtreme!
If you experience difficulties while completing this form, please email for a paper copy.

Xtreme Registration 2011-2012

Student Info

Name *

Date of Birth *

School *

Gender *

Grade *

Friend You Came With

Student Email

Student Cell Phone

Sign your student up to receive an occasional text update on upcoming events. Please choose your student's cell provider.

Parent Info

Mom's Name *

Mom's Address *

City *

Zip Code *

Mom's Home Phone *

Mom's Cell Phone *

Mom's Email *

Dad's Name *

Dad's Address

check if same as above

Street

City

Zip Code

Dad's Home Phone

Dad's Cell Phone *

Dad's Email *

Church/Volunteer Info

Do you attend Door Creek Church and if so, which campus? *

Door Creek Sprecher Campus

Door Creek North Campus

Do Not Attend Door Creek

If not Door Creek, would you like to share where you attend?

Are you interested in helping out in Student Ministries?

yes

If yes, please let us know how you would like to help.

Medical Info/Photo Release

Does your child have any specific medical needs or food allergies, chronic illness or any other conditions we should know about? If yes, please specify bleow. Also, complete and return detailed medical information form available from the church office. *

yes

Specify Here Please

In case of emergency, if parents or guardians cannot be reached, I hereby authorize treatment of first aid measure. *

yes

Parent or Guardian Initials *

Occasionally photos are taken and used in promotional brochures, instructional materials and Power Point presentations at Door Creek Church or in its website. I authorize the use of my child's image for these purposes, if needed. *

yes

Parent or Guardian Initials *