HSlifegroup
Get connected at Northeast Christian Church in a High School Life Group!  These groups are to help heal, grow, mature, and be

You will receive a confirmation e-mail from a staff member from Northeast regarding your registration within 48 hours of your
online registration.  If you do not receive this, you are not registered!

PLEASE FILL OUT FORM COMPLETELY.  Thanks!
Student Name:    
Address:         
City, State, Zip
Phone:  
Gender:  Female      Male
Date of Birth: 
Grade: 
Two friends (same gender and grade):

Is Northeast Christian Church authorized to approve medical treatment?    Yes
Is student personally covered by parent or guardian's medical insurance?   Yes
Insurance Company Name: 
Policy/group number:
State of issue:
Policyholder's Name and DOB:
Insurance Company Phone: 
Customer Service Number (if different): 
Insurance Claims Address: 
Is student currently taking prescription drugs:  Yes     No
If yes, please list:
If you could have a theme song for your life what would it be? 
If you had $10,000 to spend in one store, which store would it be and how long would it take you to spend it there? 
Give three reasons why there are holes in Swiss cheese: 
If you could have any super power, what would it be and why? 
Would you rather meet the Jonas Brothers or meet Miley Cyrus? 

Last year I went to a Life Group all the time and loved it.  My Life Group leader last year was: 



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