Immaculate Conception Church
Youth Ministry Program
2016-2017
Our First Meeting will be on Thursday September 22nd, in the Valley Program School Gym. Bring this registration form with you or fill one out at the meeting. Doors open at 6:30pm and the meeting will be from 7pm-8:30pm
Your Information
Please help us out! Write neatly! 
 
Name
Address
City                  State                          Zip Code     
Home #                                    Your age                                                                                                  
Mom’s name                           Dads Name      
Your Email (please print clearly)
Address:                                      @                               .com
School Attending                        Grade
Date of Birth                                                   
Your Cell# (if you have one)