Experience Day Registration

Student Name *

First

Last

Gender *

Date of Birth *//

Year of High School Graduation *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone Number *

Email *

Home Church (name/city) *

T-Shirt Size *

Will you be with us for the full Experience, or only on Monday? *

Are you planning to stay in the BICS dorms on Sunday night? *

Are you attending Experience Day with your parent/guardian? *

Do you have any food allergies? *

Who else is joining you for Experience Day?

e.g. friend(s), youth pastor, etc.

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Parent/Guardian Phone *

Additional Comments

Name