Please complete this form to ensure that all of your information is up-to-date for the 2018-19 season!

Youth Information

Date of Birth (MM/DD/YYYY)*
School- Other
Youth's Email*
Confirm Email*
Youth's Phone #*
State / Province*

Parent/Guardian Information

Parent/Legal Guardian Name (First & Last)*
Parent/Legal Guardian Street Address*
Parent/Legal Guardian Zip Code*
Parent/Legal Guardian Primary Phone*
Parent/Legal Guardian Cell/Alternate Phone*
Parent/Legal Guardian Email*
Does your child have permission to walk/bike/take public transportation home?
  • Yes
  • No
Adults authorized to pick up youth from the program (Please list all)

Emergency Treatment & Medical Information

Emergency Contact Name*
Emergency Contact Relationship to Youth*
Emergency Contact Phone*
Youth's Allergies/Medical Conditions (physical & mental health)*
Youth's Medications*
Insurance Company
Insurance Policy #
Policy Holder's Name

Security Code

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