Are you under the age of 18? *

Demographics *

Tip: Adults are considered 18 or over ; Youth are 13-18 yrs; and a child is 1 month-12 years of age.

First Name *

Last Name *

Middle Name *

Preferred Name

Date of Birth *

Gender *

Ethnicity * WhiteBlackHispanic or LatinoAsianNative AmericanOther

If other was selected, please list... *

Which school do you attend? *

School Grade *

Special Needs / Medical Conditions? *

Tip: Does this child have any "Special Needs" or "Medical Conditions" that we need to be made aware of?

If yes, please explain... *

Any food allergies? *

If yes, please explain... *

Marital Status *

Anniversary *

Are you currently employed? *

Occupation *

Employer *

Mobile Number *

Email Address *

Home Address *

Home Address Line 2

Home City *

Home State *

Home Zip Code *

Home Country *

Is your mailing address the same as your home address? *

Mailing Address *

Mailing Address Line 2

Mailing City *

Mailing State *

Mailing Zip Code *

Mailing Country *

First and Last Name *

Phone Number *

Are you a born again believer in Jesus Christ? *

Have you been Baptized by water?