Youth Registration Form

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First Name:     

MI:             

Last Name:      

Address:        

Address:        

City:           

State:          

Zip:            

Phone:          

Email:          

Your Sex:

Male 
Female 
Decline to Answer 

Your Race:

White 
Black 
Asian 
Hispanic 
American-Indian 
Other 

If you are part of a youth group, please list your youth group's name here:
Youth Group: 

We offer t-shirts to commemorate this event. Please tell us how many you would 
like:
Number LG shirts Number XL shirts = NUMBER TOTAL SHIRTS

Registration costs $5.00 normally, but since you are pre-registering, your
costs is only $3.00. You may pay by cerdit card online, or mail us cash or check.
Please fill in payment information here:

Number T-shirts x $18.00 each =                 
Registration Fee (optional) @$3.00 =        +   
TOTAL COST (add registration plus t-shirts) =   

Pay by: Visa/MasterCard Discover Cash Check/Money Order

If paying by check/money order, enter check or money order number here:

If paying by credit card, enter following information:
Card Number:      
Expiration date: 

You will receive an e-mail receipt from us as soon as we receive your payment. 
Please mail payment today if not paying by credit card.

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