Please fill out the form below if you will be attending Peninsula City Youth in 2017. Thanks!

Full Name *
First Name
Middle
Last Name
Parent's / Guardian's Names *
Gender *
Date of Birth*
Address *
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Home Phone
Mobile Phone*
Email*
When did start coming to Peninsula City Youth?*
School*
Year Level
Do you come to Peninsula City Church on Sundays?
Do your parents come to Peninsula City Church on Sundays?
Do you live at home with:
Do you have any medical conditions or take any medications?*
If yes, please explain
Do you accept that Peninsula City Youth is a drug, alcohol and bullying free zone?*
Do you accept that Peninsula City Leaders have duty of care. This means you must be under leaders' direct supervision at all times (eg. no leaving the church property)?*