Pennsylvania Family Council

Registration Form: City on the Hill July 23-29, 2023

Applicant must be a Christian youth 15 – 18 years of age (unless otherwise approved by the conference administrator), be enrolled in high school (or recently graduated), or currently being home schooled at the high school level; and must desire to learn how to apply their faith to become a leader among their peers; Completed application with follow-up forms must be submitted or postmarked by June 30, 2023.

This online form is the first step in completing your full application for City on the Hill.

Student Information

Student First Name

Student Last Name

Student Email Address

Student Mailing Address

Student Mailing City

Student Mailing State

Student Mailing Zip

Student Birthdate

Student Age

Student T-Shirt SizeSMLXL

GenderMaleFemale

Preferred Name on ID Badge

How did you hear about City on the Hill?

Parent Information

Parent Name

Parent Email

Parent Phone

Church Information

Pastor, Priest, or Youth Leader's Name

Church Name

Church Address

Church Phone

Church Email

School Information

Name of High School

School Address

School Phone

Contact Info

I am donating as a...

Organization Name

First Name

Last Name

Country

Address 1

Address 2

Postal Code

City

State/Province

Phone Number

Phone Type

Email Address

Yes, I would like to receive email communications.Yes, I would like to receive email communications.

COTH Registration Fee

Frequency

Interested in Scholarship Information (first time students only)YesNo

Payment Info

Card Number

Card Type

Expiration Month

Expiration Year

Name On Card

CVV Code

Account Number

Routing Number

Name On Account

Account TypeCheckingSavings

Billing Address 1

Billing Address 2

Billing Postal Code

Billing City

Billing State

Billing Country

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