Middle School Mission Registration Page

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Step 1 of 4

Parent/Guardian Information

Parents/guardians please complete this section.

Parent/Guardian Name:*

First Last

Parent/Guardian Mailing Address*

Street Address City State ZIP Code

Parent/Guardian Home Phone:*

Parent/Guardian Work Phone:

Parent/Guardian Cell Phone:

Parent/Guardian Home Email:*

Enter Email Confirm Email

Parent/Guardian Work Email:

Enter Email Confirm Email

Is there a Second Parent/Guardian to register?*

Yes

Second Parent/Guardian Name:

First Last

Is the Second Parent/Guardian's mailing address the same?

Yes

Second Parent/Guardian Mailing Address

Street Address City State ZIP Code

Second Parent/Guardian Home Phone:

Second Parent/Guardian Work Phone:

Second Parent/Guardian Cell Phone:

Second Parent/Guardian Home Email:

Enter Email Confirm Email

Second Parent/Guardian Work Email:

Enter Email Confirm Email

Emergency Contact Information

In the event of an emergency, parents will be contacted first. Please add additional contacts in the event we cannot reach you immediately

First Emergency Contact:

First Last

First Emergency Contact Home Phone:

First Emergency Contact Cell Phone:

Second Emergency Contact:

First Last

Second Emergency Contact Home Phone:

Second Emergency Contact Cell Phone:

Health Information

Family Physician:

Physician Phone:

Any conditions or allergies (food, drugs, etc.) which may affect the participant's involvement in the event?*

Yes

Please list any medical concerns (e.g. allergies) that your child has and that we need to be aware of:

Any physician prescribed or other medication which the participant may be taking during the event?*

Yes

Please provide name, dosage, and potential side effects of medication(s):

Payment

The investment for Middle School Mission All Saints in-parish participants is $80. (The investment for out-of-parish participants is $90.)

Our online payment system is 100% safe and secure – you can save time and complete your registration today! We do not save, store, or see any of your credit card details.

Middle School Mission – Parishoner

Price:

Middle School Mission – Non-Parishoner

Price:

Would you like to save yourself time and pay online right now?*

Yes, I’ll save time and pay securely right now!

No, I’ll give you a check.

Note: Because demand is usually high for our events, your registration will NOT be fully confirmed until we have received payment.

Billing Details

Credit Card

Card Details

Cardholder Name

Billing Address:*

Street Address Address Line 2 City State ZIP Code

Total:

Check Payment Instructions

Please make your check payable to “All Saints Youth Ministry”

Drop off in person: All Saints School or Parish Office.

Or mail to: All Saints Youth Ministry, 9300 Stonewall Rd, Manassas, VA 20110

Remember, because demand is usually high for our events, your registration will NOT be fully confirmed until we have received payment.

Please make your check payable to “Holy Trinity”

Drop off in person: At the parish office (office hours are found online at www.holytrinityparish.net).

Or mail to: Holy Trinity Parish, 8213 Linton Hall Road Gainesville, VA 20155

Please note because demand is usually high for our events, your registration will NOT be fully confirmed until we have received payment.

Total Due:

Student Information

Participant's Commitment

Parent/Guardian Information

Emergency Contact Information

Health Information

Parent Involvement

Parental Permission & Liability Release:

Payment

Billing Details

Check Payment Instructions

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