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High School Youth Group 9-12 registration

- Please complete the form below to register to participate in the High School Youth Group.
  Registration is free!
- High School Youth Group Registration
  
  The maximum number of form submissions has been reached. This form is currently not available.
  
  Parent Name (First and Last Name) REQUIRED Please fill out this field. Please enter valid data.
  
  Student Name (First and Last) REQUIRED Please fill out this field. Please enter valid data.
  
  Student Preferred Name Please enter valid data.
  
  Street Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  What school do you attend? REQUIRED Please fill out this field. Please enter valid data.
  
  Grade (grade rising to in the fall) REQUIRED 9th grade 10th grade 11th grade 12th grade Please fill out this field.
  
  Are you allergic to anything? (kept confidential / for staff purposes only) REQUIRED Yes No Please fill out this field.
  
  Please specify any allergies (food, medications, etc.) Please enter valid data.
  
  Do you have any emotional, physical or sensory conditions? (kept confidential / for staff purposes only) REQUIRED Yes No Please fill out this field.
  
  Please specify any physical and/or sensory conditions we should be aware / special accommodations. Please enter valid data.
  
  Submit
- Paul Flagg
  
  Youth Ministry Coordinator
  
  (540) 344-9814 ext. 157
  pflaggbofsa.org