Generic Registration Form-Concordia Lutheran Church Jamestown ND LCMS

You may submit your form electronically or print it out and bring it in.

If you are under 18, this form MUST be signed at the bottom by a parent or legal guardian.
YOUR REGISTRATION IS NOT FINAL UNTIL YOU HAVE PAID THE DEPOSIT FOR THIS EVENT.

Full Name:
Event:	What's this?
Autofill_Password(optional):
Autofill:
Mailing Address:
City, State Zip:
Birthdate:
Email:
Parent Names:
Parental Numbers:
Secondary Contact:
Secondary Numbers:
Insurance Company:
Ins. Phone Number:
Insurance ID #::
Allergies:
Medications:
Additional Info:
Set Autofill to:	On - Off
	Permission Signature of Parent/Guardian: ___________________________________________________

Concordia Lutheran Church - Jamestown, ND