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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