Church Leader: JP Participant Roster
Week attending the Jeremiah Project:
*
Please Select
June 26-July 2 (Middle School Only, Winchester, VA)
July 3-9 (Middle School Only, Winchester, VA)
July 3-9 (Combined, Romney, WV)
July 10-16 (Combined, Romney, WV)
July 17-23 (Combined, Romney, WV)
July 24-30 (Combined, Romney, WV)
Name
*
First Name
Last Name
Church Name
*
Spelled out, no abbreviations
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
What grade will he/she have completed in June 2022?
*
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
Adult Leader
Birth Sex
*
Male
Female
Dietary, Medical or Allergies Concerns? Please explain:
Other notes or important information:
Help us better serve your students by informing us of any emotional or behavioral concerns ahead of time. We will also work with you one on one to ensure we are equipped to work with, serve, and care for your students while they are with us at JP!
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