Confirmation Registration

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Confirmation Registration

Confirmation Registration

CONFIRMATION REGISTRATION

YEAR 2013-2014

Select Program Year

Year 1
Year 2
Other:

Full Name *

Age *

Street Address *

City *

Zip Code *

Phone Number (best contact number) *

E-mail Address (best for contact and response) *

Fathers Full Name *

Mother's First and Maiden Name *

Emergency Contact Person (Name)

Emergency Contact Person (Phone Number)

Date of Birth

City of Birth

State or Country of Birth

Date of Baptism

Place of Baptism (Full Name of Church)

City of Baptism

State or Country of Baptism

Full Name of Sponsor (Year 2 only)

I agree to pay the 150 dollar (Year 1) or 200 dollar (Year 2) registration fee

In Total on September 10th
Monthly withdrawal from my checking account (Provide information on September 10th)
Other:

Questions or Concerns

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