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Participant Registration
*Participant's First Name:  __________________________________
*Participant's Last Name:  __________________________________
*Preferred Name for Name Tag:  __________________________________
*Gender:  Male  Female  (circle one)
*Birthday:  __________________________________
*Last Grade Completed:  __________________________________
Allergies, Medical, & Special Needs:
*Parent/Guardian Name:  __________________________________
*Address:  __________________________________
*City:  __________________________________
*State:  __________________________________
*Zip:  __________________________________
*Cell Phone:  (______)______-________
*Cell Phone Carrier:
*Email:  __________________________________
*Emergency Contact Name (1):  __________________________________
*Emergency Contact Phone (1):  (______)______-________
*Emergency Contact Name (2):  __________________________________
*Emergency Contact Phone (2):  (______)______-________
*Authorized Pickup #1:  __________________________________
*Authorized Pickup #2:  __________________________________
Do you attend Mercy Church?:    Y   N  (circle one)
If so, which campus do you attend?:    Mercy Providence Road
   Mercy Northeast  (circle one)
Do you attend another church?:    Y   N  (circle one)
If so, which church?:
*Photograph Use:    Y   N  (circle one)
* Required