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C4 Registration Form

* indicates a required answer.

1. *

Parents' Names

2. *

Street Address

3. *

City

4. *

State

5. *

Zip

6. *

Cell Phone (xxx-xxx-xxxx)

7. *

Home Phone (xxx-xxx-xxxx)

8. *

Email

9. *

#1 Student Name

10. *

Student Email

11. *

Student Cell (xxx-xxx-xxxx)

12. *

Birthdate

13. *

Allergies

14.

Choose ONE

 
Speech (ages 12-18) Childcare (ages 7 and under)
Junior Speech (ages 8-11)
15.

#2 Student Name

16.

Student Email

17.

Student Cell (xxx-xxx-xxxx)

18.

Birthdate

19. 

Allergies

20.

Choose ONE

 
Speech (ages 12-18) Childcare (ages 7 and under)
Junior Speech (ages 8-11)
21.

#3 Student Name

22.

Student Email

23.

Student Cell (xxx-xxx-xxxx)

24.

Birthdate

25. 

Allergies

26.

Choose ONE

 
Speech (ages 12-18) Childcare (ages 7 and under)
Junior Speech (ages 8-11)
27.

#4 Student Name

28.

Student Email

29.

Student Cell (xxx-xxx-xxxx)

30.

Birthdate

31. 

Allergies

32.

Choose ONE

 
Speech (ages 12-18) Childcare (ages 7 and under)
Junior Speech (ages 8-11)
33.

#5 Student Name

34.

Student Email

35.

Student Cell (xxx-xxx-xxxx)

36.

Birthdate

37. 

Allergies

38.

Choose ONE

 
Speech (ages 12-18) Childcare (ages 7 and under)
Junior Speech (ages 8-11)

       

Payment by check ONLY.

Checks payable to: Capital Baptist Church (Memo: C4 Club Registration)

Payment AND Parent/Student Agreement have to be mailed by June 15 to get the Early Bird Registration rate to:

Jennifer Chang

4413 Duncan Drive

Annandale, VA 22003

Click below to continue to the Membership Agreement (Complete the form and mail both your check and the agreement form to Jennifer Chang). This step is required for registration.

Membership Agreement