Guys'/Girls' Night
February 21, 2026 3:30pm | Please submit a form for each participating student.
Name
*
Parent/Guardian's Name
*
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Email
*
This address will receive a confirmation email
Cell Phone
*
Do you currently attend a church?
*
Please select all that apply.
Yes
No
If you currently attend church, where?
I, the parent/legal guardian, give full consent and approval for my child to attend and participate in 4:12 Youth Ministries Guys'/Girls' Night on February 21, 2026 with Millersville Baptist Church. I agree that my child will abide by all the rules and expectations set forth by Millersville Baptist Church. I acknowledge and understand that attendance is voluntary. I also acknowledge and understand that all normal precautions will be taken during this event and that no leader, or Millersville Baptist Church will be liable or responsible in the event of an unforeseen accident or injury.
*
Please select all that apply.
Yes
Do you give permission to Millersville Baptist Church to use photographs and/or videos of my child in print or online materials designed for promotion or informational purposes related to Millersville Baptist Church.
*
Please select all that apply.
Yes
No
Electronic Signature*
*
*By entering my name in the box, I am providing my digital signature on this form. I attest that all information is correct to my knowledge.
Submit
Description
February 21, 2026 3:30pm
Please submit a form for each participating student.
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