Participant Information

I am currently a...
*

Freshman

Sophomore

Junior

Senior

Last Name *

First Name *

Sex *

tshirt *

DOB (MM/DD/YYYY) *

School *

Teen's Cell (913.888.7777) *

Household / Adult Primary Contact

Mom's Name *

Dad's Name *

Address 1 *

City *

State *

Zip *

Phone (i.e. 913.888.7777) *

Emergency/Cell Phone

Home Parish *

Updates will be sent via email.

Parent's Email Address *

Teen's Email

Which day(s) of the week could you meet with a small group? *

Monday

Tuesday

Wednesday

Thursday