RCM Registration Page

Please fill out this form in its intirety with as much information as possible
Please note that all of this information is kept strictly confidential.

We take strong measures to keep your information private and secure.
The information you provide with us here is NOT circulated to any third parties.

Personal Information:

This is used to determine your identity, contact you and relay important information.

*First Name:
*Middle Initial:
*Last Name:
*Gender:	Male Female
*Birthdate:
*Address Line 1:
Address Line 2:
*City:
*State:
*Zip Code:
	i.e. (555) 555-1234
*Home Phone:
	i.e. (555) 555-1234
Cell Phone:
* denotes a required field

Email contact information:

Email is an easy way for us to contact you regarding important information
This may include possible closings due to inclement weather or other important annoucements.

**Email:

The RCM Newsletter is seperate from important announcements and will be sent to all people who sign up below.
The Newsletter will inform you of important upcoming events and activities at RCM and other local youth events.

Please choose whether or not to receive this newsletter with the buttons below:

**Receive Newsletter?:	Yes No
**Note: If you choose 'yes' above you MUST provide a valid email address.

Medical Information:

Please list any medical concerns we should be concerned about while you are in our care.
These may include asthma, seizures or any other important medical information.

Medical Information:

School Information:

Please describe your school information below.
This will help us determine specific events for your area.

*Grade:
	i.e. Smithsburg High, or Home Schooled
*School Name:
Extra Curricular:
* denotes a required field

Male Parent/Guardian Information:

Please list information about your male parent/guardian.
This information is used to be able to contact your parent/guardian for emergency purposes.

***First Name:
***Last Name:
Email:
***Note: At least one parent/guardian is required

Female Parent/Guardian Information:

Please list information about your female parent/guardian.
This information is used to be able to contact your parent/guardian for emergency purposes.

***First Name:
***Last Name:
Email:
***Note: At least one parent/guardian is required

Internet Contact:

Please list any contacts you may have below.
These may be used to better inform you of upcoming events and information.

AIM:
MSN:
ICQ:
Yahoo!:
	i.e. http://www.myspace.com/example
Myspace Link: