The Summit Registration | Pathfinder Church

Student Information

Student Name*

First Last

Student Birthdate*

MM

DD

YYYY

Gender*

Student Address*

Street Address Address Line 2 City ZIP Code

Student Main/Home Phone*

Student Cell Phone

Cell Phone Carrier (ie. Verizon)

Student Email

Grade*

9th
10th
11th
12th

Name of School*

Allergies and/or Special Needs

Is there anything we should know about your child that will enable us to better serve your child? If so, please describe them above or call to discuss.

How did you hear about The Summit?*

Parent One Information

Parent 1 Name*

First Last

Parent 1 Address*

Street Address Address Line 2 City ZIP Code

Parents 1 Main Phone*

Parent 1 Cell Phone*

Parent 1 Email*

Parent 2 Information

Parent 2 Name

First Last

Parent 2 Address

Street Address Address Line 2 City ZIP Code

Parent 2 Main Phone

Parent 2 Cell Phone

Parent 2 Email

Friend Request For Small Group Assignment

Students, please enter a friend or mentor request below. If possible, we will place you with students from your school if you do not have a request.

Friend Request

First Last

Mentor Request

First Last

Freshman/Sophomore Female Leaders: Alice Patton, Katie Lorenz, Allie Antle --- Freshman/Sophomore Male Leaders: Steve Patton, Jon Dunn, Eric Breyer --- Junior/Senior Female Leaders: Kelly Shepherd, Denyse Bozzay, Katie Pomp --- Junior/Senior Male Leaders: Cool John Solter, Jon Shepherd

Parent Permission

The registrant has my permission to participate in Pathfinder Student Ministry programs and related activities, to include the Sunday evening high school program, The Summit. I understand that when participating in Pathfinder Student Ministry activities, the registrant may be photographed for print, video, or electronic imaging. I understand the images may be used in promotional materials for Pathfinder Church. I acknowledge the images will be the sole property of Pathfinder Church.

Click below to accept*

I accept