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Youth Center Registration
Youth Center Registration
1
Registration
2
Transportation
3
Demographics
4
Sign and Submit
Registration
Program
*
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Parent/Guardian Information
Parent/Guardian First Name
*
*
Parent/Guardian Middle Name
*
Parent/Guardian Last Name
*
*
Parent/Guardian Relationship
*
Father
Mother
Guardian
Parent/Guardian Occupation
*
*
Parent/Guardian Employer
*
*
Email
*
*
Phone Number
*
*
Message Number
*
*
Work Number
*
*
Address
Street
*
*
City
*
*
State
*
*
Zip Code
*
*
Child Information
Child First Name
*
*
Child Middle Name
*
Child Last Name
*
*
Date of Birth
*
*
Age
*
*
*
Gender
*
Male
Female
Non-Binary
Other
Prefer To Self-Define
Prefer Not To Disclose
School
*
*
Grade
*
*
Emergency Contact Information
Emergency Contact Name
*
*
Emergency Contact Phone
*
*
Emergency Contact Relationship
*
*
Emergency Contact Address
*
*
Name of Doctor
*
*
Doctor Phone
*
*
Preexisting Medical Conditions (will not bar you from program)
*
*
Medications
*
*
Food Allergies
*
*
