*

Children's Program (5-10)

Junior Youth Empowerment Program (11-13)

Youth Program (14-18)

Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

I hereby give permission for my child to be included in videos and/or photographs as they participate in all activities for the purpose of capturing, celebrating, and promoting the Program (e.g. pamphlets, display boards, presentations, annual reports). *

If participant is over 18, they can answer themselves.

Yes

No

I authorize my child to participate in the program *

If participant is over 18, they can answer themselves.

Yes

No

Parent Name *

First Name

Last Name

Emergency Contact Number

(###)

###

####