Saint John's Evangelical Lutheran Church
48 Greene Avenue, Sayville, New York 11782
Office: (631) 589-3202 - Fax: (631) 589-1419 - E-Mail: stjohns11782@aol.com
Rev. Brian Noack, Pastor

REGISTER FOR YOUTH EVENTS HERE

Fill out form below and "submit" it or print form and drop it at our office, mail or fax it to above #.

NAME AGE

ADDRESS

CITY STATE ZIP

HOME # CELL # CELL #2 HOME EMAIL ADDRESS

DATE OF BIRTH LAST SCHOOL GRADE COMPLETED

IN CASE OF EMERGENCY, CONTACT

MOM DAD OTHER

ALLERGIES/OTHER MEDICAL CONCERNS

My child’s physician is: Phone #

Insurance company: I.D.#

Please feel free to call me with any questions, contact Chris Abatelli, Youth Director, 413-626-8841