Youth Registration Form

Program Name *
Program Location *
Program Date *

Student Information

First Name *
Last Name *
Email Address *
Address *
City *
State *
Zip/Postal Code *
M / F
Please list any food allergies and/or special requirements:

Parents / Guardian

Father's Name *
Father's Phone Number
Father's Email Address *
Father's Address *
Mother's Name *
Mother's Phone Number
Mother's Email Address *
Mother's Address *

If neither parent can be reached, in case of an emergency, contact:

Name *
Phone Number
Relationship *

Cancellations / Refunds

Cancellations must be received fourteen (14) days prior to the start of a program for full refund. Full refunds will be made in the event that the minimum required enrollment of ten (10) participants is not reached.