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Pure Rebellion Adult Registration

The form below is used to enter the registration for one or two parents.  Enter information in all the pertinent fields, and click Submit at the bottom of the form

You will be forwarded to the payment screen.

Enter the following information:

  • Select Parents as the Type of Registration from the drop down list
  • Enter the Name of the Parent for payment reference
  • Enter the total number of parent registrations being made

Click on Buy Now. You will then be forwarded to the PayPal screen for online payment for registration.  PayPal is a secure site for online payment.

Registration for your students and adultts is not valid or complete until payment is made.

If this is not the type of registration you want, click RETURN  to go back to the previous page.

The form below is used to enter the registration for one or two parents.  Enter information in all the pertinent fields, and click Submit at the bottom of the form

You will be forwarded to the payment screen.

Enter the following information:

  • Select Parents as the Type of Registration from the drop down list
  • Enter the Name of the Parent for payment reference
  • Enter the total number of parent registrations being made

Click on Buy Now. You will then be forwarded to the PayPal screen for online payment for registration.  PayPal is a secure site for online payment.

Registration for your students and adultts is not valid or complete until payment is made.

If this is not the type of registration you want, click RETURN  to go back to the previous page.

Pure Rebellion Adult Registration
Adult (1)
First Name*
Last Name*
Address*
City,State,Zip*
Primary Phone #*
Email Address
Church
Church City Location
Adult (2)
First Name
Last Name
Submit