REGISTRATION EMPOWERED 2020

Last Name
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First Name
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Age
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Birth Date [Month/Day/Year]
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Gender
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Email Address
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Your Cell Phone Number
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Parent's Name
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Parent's Phone Number
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Address
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- Street Address
- Address Line 2
- City
- State / Province / Region
- Postal / Zip Code
- Country
Have you accepted Jesus as your personal savior?

Yes
No
Do you go to church?
Yes
No
If yes, write the name of your church:
If you are ages 13 and up, choose your preferred time:
Some of the pictures taken during this virtual event may be used on our social media. Please sign below as acknowledgement.
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Please click on the checkbox to continue
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