Center Point Church - Mountain Lake

Student Information

First Name

Last Name

Birth Date

Gender
Male
Female

Grade

School

T-shirt size

Cell Number

Email

Address 1

Address 2

City

State

Zip/Postal Code

Medication Information-List Times & Dosage

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Cell Number

Parent/Guardian Email Address

Parent/Guardian Preferred Method of Contact

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Payment Details

After submitting the registration form please pay a $50 deposit to secure your spot: PAY DEPOSIT
(Remaining $99 is due October 19th)
OR
After submitting the registration form pay $149 to pay in full: PAY IN FULL

Student Information

Parent/Guardian Information

Payment Details

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