ENGAGE Freeport Registration Form 2024/2025

Please register your student/child for ENGAGE Student Ministries here at Park Hills Church.

Information

Name

*

Address

*

Birth Date

*

Gender

*

Please select one option.

M F

Weekend Worship Attendance

*

Please select one option.

At Park Hills Other

Child / Student Activities

*

Please select all that apply.

ENGAGE HS (9-12 Grade) ENGAGE MS (6-8 Grade)

Grade

*

School

*

Please select one option.

None Dakota Durand Eastland Forreston Fpt Blackhawk Fpt Carl Sandberg Fpt Center Fpt Empire Fpt High Fpt Jones Farrar Fpt Lincoln Douglas Fpt Middle Fpt St Joseph Fpt Taylor Park German Valley Home School Immanual Lutheran Le-Win Monroe Open Bible Orangeville Pearl City Pecatonica Stockton TCCS Warren Other

Shirt Size

*

Please select one option.

Adult Small Adult Medium Adult Large Adult XL Adult 2XL Adult 3XL

Allergies/Medical Needs

Student Contact Information

Please enter the student email and cell phone contact information we can use as the primary way to communicate with the student.

Email

This address will receive a confirmation email

Cell Phone

*

Parent / Guardian Contact Information

Please fill in all the areas that apply.

Mom Name

Mom Cell Phone

Mom Email

This address will receive a confirmation email

Dad Name

Dad Cell Phone

Dad Email

This address will receive a confirmation email

Guardian Name

*

Guardian Cell Phone

*

Guardian Email

*

This address will receive a confirmation email

In the case of an emergency and the parent/guardian cannot be reached, please notify

Emergency Contact Name

*

Emergency Contact Number

*

Emergency Contact Relationship to Child

*

Other Information

Other Comments

Description

Please register your student/child for ENGAGE Student Ministries here at Park Hills Church.

Please Fix the Following

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