Sign up for intermediates

First Name *

Last Name *

Mobile Number *

Tip: If you do not have a cellphone, please put a parent or guardian's.

Date of Birth *

Gender

Home Address *

School Name

Emergency Contact Full Name *

Emergency Contact Phone Number *

Emergency Contact Email Address *

Do you have a medical and/or allergy/dietary requirement *

Medical

Dietary/Allergy

None

Please describe your medical condition *

Please describe your allergy or dietary requirement *

In a few short words, why would you like to join WB Youth?

Tip: Here are a few examples of things you can write: make friends, socialise, spiritual support, emotional support, mentoring, etc.

Would you like one of our youth leaders to contact you?

Yes

I give permission for this information to be added to the Church database. *

Yes

Tip: This information is only accessible to church staff and key leaders, and is stored digitally on our secure database.

I give permission for Waikanae Baptist to contact me with the above information. *

Yes

I want to receive regular updates about youth group via email. *

Yes

All information is kept in accordance with our Privay Policy and our Youth Permissions Document