Event Registration

First Name: Last Name: Phone: May we add your cell # to the "GroupMe" app so you can receive texts in case of an emergency? Yes No Email: Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Mother's Place of employment Mother/Guardian Work Phone Name of Church you attend: What School does your child attend? Father's Name Father Cell Phone Father's Address City State Zip Code Father's place of employment Father/Guardian Work Phone Emergency Contact 1 Name Emergency Contact 1 Phone Emergency Contact 2 Name Emergency Contact 2 Phone Emergency Contact 3 Name Emergency Contact 3 Phone Physician Phone # Primary Physician Preferred Hospital Name of Policy holder Policy # I understand that I will be responsible for providing transportation for my child/children. Pick up is at 3:30 p. m. Monday - Thursday There will be a parent/student orientation on Thursday June 4 at 5:30 PM at Bridge Ministry of Acadiana Number of Attendees: