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For 3rd-5th graders - held on Wednesday nights 6:30 - 8:00 pm beginning September 3.  Registration deadline is August 31.  $25 will be required on September 3 (first night of Life Groups).

PLEASE FILL OUT FORM COMPLETELY.  Thanks!
Student Name:    
Address:         
City, State, Zip
Phone:  
Gender:  Female      Male
Date of Birth: 
Grade: 
E-mail address: 
T-Shirt Size: 
Two friends* (same gender and grade):
    *(Information not required but needed if you want to be placed in a group with your friends.
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:
Please note there will be a document for parents to fill out and sign the first night of Life Groups giving Northeast permission to transport kids for field trips.



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