Park Hills Students - Winnebago Registration Form 2026/2027

Please register your student for Park Hills Student Ministries for the 2026/2027 school year.

Student General Information

Name

*

Address

*

Birth Date

*

Gender

*

Please select one option.

M F

Weekend Worship Attendance

*

Please select one option.

At Park Hills Other

Grade

*

School

*

Please select one option.

Auburn Byron Dakota Durand Eastland Freeport Forreston Home School Monroe Oregon Pecatonica TCCS Winnebago Other

Shirt Size

Please select one option.

Adult Small Adult Medium Adult Large Adult XLarge Adult XXLarge Adult XXXLarge

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:

Your emergency contact must be a different person from the parent(s)/guardian you listed above.

Emergency Contact Name

*

Emergency Contact Number

*

Emergency Contact Relationship to Child

*

Other Information

Other Comments

Description

Please register your student for Park Hills Student Ministries for the 2026/2027 school year.

Please Fix the Following

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