progressive dinner 2019 | student registration

Sunday, December 1st, 2019

6pm - 9:30pm

Registration Deadline: Tuesday, November 26th

Medical Information Form

An up-to-date medical information form and release is needed for each student that participates in activities with MIPC Youth Ministries.  

If you already submitted an up-to-date online medical form during the 2019-2020 school year for LIVE or another event, you do not need to re-submit.


Student Cell *
Student Cell
Date of Birth *
Date of Birth
Home Phone *
Home Phone
Parent/Guardian 1 Name *
Parent/Guardian 1 Name
Parent/Guardian 1 Cell *
Parent/Guardian 1 Cell
Parent/Guardian 2 Name
Parent/Guardian 2 Name
Parent/Guardian 2 Cell
Parent/Guardian 2 Cell
Medical *
I have submitted an up-to-date Medical Information Form for my child for the 2019-2020 school year.
We don't ever want money to be a barrier for your/your student's involvement! Scholarship money is available to assist students and families with program and event payments who would otherwise be unable to participate due to financial reasons. We ask that you would pay as much as you are able, so that we are able to assist as many families as we can. All requests are confidential.
Sign Up for the MIPC Youth Newsletter
By checking this box you are agreeing to be signed up to receive our weekly MIPC Youth Middle School newsletter.