Online Registration

Class Location (select one):

Name of Church/Organization:

Address:

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Pastor/Leader's Name:

First Name

Last Name

Contact Phone Number:

E-mail Address:

Number of Students Attending:

Print Full Name of Each Student

No: 1 Name

First

Last

No: 2 Name

First

Last

No: 3 Name

First

Last

No: 4 Name

First

Last

No: 5 Name

First

Last

No: 6 Name

First

Last

No: 7 Name

First

Last

No: 8 Name

First

Last

No: 9 Name

First

Last

No: 10 Name

First

Last

I have enclosed a check in the amount of $ (list below) made payable to the CKLC:

Authorized Signature, I authorize:

If you have any questions contact: Apostle Leslie Brown, III at (954) 651 - 5197 or via e-mail: bubba.leslie@gmail.com