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Spring '10 Sunday Night High School Life Groups

Get connected with High School and grow in your faith in a Life Group!  Life Groups are here to help students heal, grow, mature, and be repaired alongside fellow students.  They are held Sunday evenings 7:15 - 8:15 pm at Northeast right after the High School program ends.

Full Name
Gender
Street Address
City/State/Zip
Date of Birth
High School
Grade


Home Phone
Student Cell Phone
I am able and willing to receive text messages from Northeast on my cell phone.
Email Address
(Two friends) must be same grade and gender)
Is Northeast authorized to approve medical treatment?
Is student personally covered by parent or guardian's medical insurance?
Insurance Company Name
Policy/Group Number
State of Issue
Policyholder's Name and DOB
Insurance Company Phone
Customer Service Number (if different)
Insurance Claims Address
Is the student currently taking prescription drugs?
If so, please list
Please answer the simple math question below to submit the form.
2 + 2 =

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