NERD Youth Registration 2026

Alert: Required for children between the ages of 5 to 12.

Child's Information:

Child's Name

Child's Age

Child's Phone

Home Address

Parent's Information:

Parent's Name

Parent's Email

This address will receive a confirmation email

Parent's Phone

Alternate Contact Information (If Applicable):

Additional Contact's Name

Additional Contact's Phone

Church Information:

Please enter your full church name, abbreviations are not acceptable.

Church Name

Pastor's Name

Payment Information:

Payment Due $25.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Please fill out this form to register your child for the North East Diocese State Conference.