Illinois Student Ministries

This form to filled out by each Church's Breakaway Kids Coordinator ONLY please!

If you are looking for the Teen Coordinator Sign Up, please use this link instead.

* indicates required

Email Address *

First Name *

Last Name *

Phone Number

Address

Street Address Address Line 2 City State/Prov/Region Postal/Zip Country

Church Name *

Church City *

Is this an Assemblies of God Church? *

Yes
No
I do not know

# of Students: *

# of Leaders: *

# of Leaders you expect to bring.

Were you the Coordinator for this church last year

Breakaway'24 Kids Coordinators