Registration | First Presbyterian Church of Wilmette

Registration

Name(required)

Grade(required)

Birthday(required)

Youth Email address(required)

Youth Cell Number(required)

Home Phone(required)

Home Address(required)

Parent #1(required)

Cell(required)

Address(required)

Parent #2 (if applicable)

Cell

Address

Emergency Name & Number(required)

Special Needs or Medications/Allergies(required)

Name of Primary Insured(required)

Employer of Insured

Policy#(required)

Group#(required)

Extracurricular Activities?(required)

Instrument or Sing?(required)

Email address(required)

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