Young People’s Christian Assembly Registration Form

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Name of Church*
Pastor Name*
Prefix First Last
Address*
Street Address Address Line 2 City State ZIP Code
Number of Young People Your Church Will Sponsor:*
Contact Person*
First Last
Email*
Phone
Please enter below the sponsored students and chaperones, age, sex, and year of attendance below. (ONE NAME PER LINE)*
Enter name of sponsored students & chaperones, age, male/female, year of attendance (ONE NAME PER LINE)
Registration Fee Per Person*
Price: $120.00 Quantity:
Enter the number of sponsored students and chaperones.
Grand Total
$0.00
Credit Card
American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name