Jamie Robbins Youth Scholarship Application

"*" indicates required fields

First Name*

Last Name*

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Applicant's Age*

Please enter a number less than or equal to 18.

Is this your first conference at Green Lake?*

Yes

Church Name*

Church City & State*

Church Phone Number*

Conference Attending*

Arrival Date*

Departure Date*

Confirmation Number

Where are you staying?

Group leader's name

Group leader's phone number

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