Girls Ministry Registration Please enable JavaScript in your browser to complete this form.NameFirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome PhoneCell PhoneEmailShirt SizePersonal InformationDate of BirthGradeGirl's Date of SalvationDo you attend church?YesNoWhere do you attends church atFather's NameFirstLastMother's NameFirstLastMpact Group (Select one)Grades K-2Grades 3-5Emergency Medical InformationFamily Doctor's NameFirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDoctor's PhoneIs your child allergic to penicillin?YesNoDate of last Tetanus shot (if known)Medications - Please listOther Allergies, Medical Problems and/or Learning DisabilitiesMedical PermissionClear SignatureIn case of emergency and I cannot be located, I authorize Mpact to secure emergency medical care for my child. I hereby give the Mpact Staff permission to render first aid, take my child to the hospital in an emergency, and permission for a physician to give or order any necessary treatment. SignatureClear SignatureToday's DateGirl's Ministry yearly cost Price: $ 20.00WebsiteSubmit Share this:TwitterFacebookLike this:Like Loading...