Program Registration

  

Preschool Aquatics Levels 2

Cost: $32

Registrant Name: Registrant Age:
Registrant D.O.B.: Registrant Grade:
Parent/Guardian Name: Address:
City: State:   Zip:
*E-Mail: *Phone #:
Church: Pastor / Youth Leader:
Email: Phone:
Allergies: Specify:
*Comments & Concerns:
(Dietary Needs, Sleeping Habits, etc.)

Your registration is not complete until your payment is received and
you receive an email confirmation from the Peniel Office.

You are registering over a secure connection.