Young People’s Christian Assembly Registration Form Learn More Visit Apply Home » Young People’s Christian Assembly Registration Form Name of Church* Pastor Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of Young People Your Church Will Sponsor:*123456789101112131415161718Contact Person* First Last Email* PhonePlease 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 ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name