Rent-a-Teen Request Form

Sign Up to Participate in a Rent-A-Teen Fundraising Activity

Have fun and earn credit towards Summer Mission Trips!
Sign me up for the following Rent-A-Teen Activities:
  • Parent's Night Out (October 24 at 6:00-9:45 PM)
  • On-Call (Miscellaneous Opportunities/Odd Jobs)
Name (first & last):
Birthdate: (MM/DD/YYYY)
  • Male
  • Female
Parent's name:
Home Phone:
Cell phone:
Email address:
Emergency contact name (after parents):
Emergency contact's phone:
Insurance Name:
Policy Number:
Group ID Number
Policy Holder's Full Name
Insurance Company Telephone