CTYM Registration Form

Please use this form to register your children for participation in Chandelier Transformations Youth Mentoring 2026-2027. Payment plans and scholarships available. Registration using this form is effective for:

Group	School Year	When	Cost
Elementary School Mentoring	(3rd - 5th Grades)	In person	Registration: Regular Registration Fee: $125 Monthly: Regular Price per month: $75 (10 months)
Middle School Mentoring	6th-8th Grades	In person	Registration: Regular Registration Fee: $125 Monthly: Regular Price per month: $75 (10 months)
High School Mentoring	9th-12th Grades	In person	Registration: Regular Registration Fee: $125 Monthly: Regular Price per month: $75 (10 months)
Teen Summit	2022	TBD	TBD
Leadership Workshop	2022	TBD	TBD

Summer Camp	2022	TBD	Regular Price: $50 per week

More information about Chandelier Transformatoions Youth Mentoring can be found on our website: www.CTYM.org

Chandelier Transformations Youth Mentoring (CTYM) Registration Form

Please use this form to register your children for participation in Chandelier Transformations Youth Mentoring INC. 2023-2024. Payment plans and scholarships available. Registration using this form is effective for:

Group	School Year	When	Cost
Aftercare	2024 - 2025 3rd -5th Grades 6th-8th Grades 9th-12th Grades	In person	Registration: Regular Registration Fee: $75 Monthly: Regular Price per week: $75 (Aftercare Participants automatically eligible to participant in monthly mentoring Saturdays)
Monthly Mentoring	2023 - 2024 3rd -5th Grades 6th-8th Grades 9th-12th Grades	In person	Registration: Regular Registration Fee: $125 Monthly: Regular Price per month: $50

Teen Summit	2025	TBD	TBD
Leadership Workshop	2025	TBD	TBD
Summer Camp	2025	TBD	TBD

More information about Chandelier Transformatoions Youth Mentoring can be found on our website: www.CTYM.org

My Products*

Registration Fee$125.00

Registration Fee Monthly Mentoring

Quantity

After Care$300.00

Monthly Aftercare (4 Weeks)

Quantity

Monthly Mentoring Fee$50.00

Monthly Mentoring Fee

Quantity

Enter coupon

Total $0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Form Instructions

*The tabs below will expand as you click on them

1. Complete Parent/Guardian Information (including alternative pick up and emergency contact persons)

2. Add registration details for each of your children (up to 3 per family) and select all the applicable ministry groups for each child

NOTE: This year, in accordance with regulations surrounding children's activities we're asking you to submit your Insurance details in relation to your child(ren). Thank you for your understanding.

3. Submit Registration

PARENT/GUARDIAN INFORMATION
Parent/Guardian #1
First Name*
Last Name*
Address*
E-mail*
Phone Number*
Parent/Guardian #2 (if applicable)
First Name
Last Name
Address as above
Address
E-mail
Phone Number
Alternative pick-up

I give permission for the following people to collect my child(ren) from their ministry activities:
Enter names
Emergency Contacts

In the event of an emergency this person will be contacted if the parent/guardian cannot be reached:
Full name

First NameLast Name
Phone Number
Relationship to child(ren)

ADD CHILD 1
CHILD "1" INFORMATION
First Name*
Last Name*
Date of Birth*

DayMonthYear
Gender*
2023-2024 School Year (if applicable)
2023 School Attended (if applicable)
Email (if applicable)
example@example.com
Mobile Number (if applicable)
Insurance Subscriber Number
Insurance Position on Card
E.g 1, 2, 3..etc in order of age
Insurance Expiry Date
E.g 02/2024
Please supply full details of any allergies or dietary conditions experienced by this child
Please supply full details of medications or medical conditions experienced by this child
Is there anything else that we should know about your child? (e.g. known behavioural issues).

ADD CHILD 2
CHILD "2" INFORMATION
First Name
Last Name
Date of Birth

DayMonthYear
Gender
2023-2024 School Year (if applicable)
2023 School Attended (if applicable)
Email (if applicable)
example@example.com
Mobile Number (if applicable)
Medicare Number
Medicare Position on Card
E.g 1, 2, 3..etc in order of age
Medicare Expiry Date
E.g 02/2024
Please supply full details of any allergies or dietary conditions experienced by this child
Please supply full details of medications or medical conditions experienced by this child
Is there anything else that we should know about your child? (e.g. known behavioural issues).

ADD CHILD 3
CHILD "3" INFORMATION
First Name
Last Name
Date of Birth

DayMonthYear
Gender
2023-2024 School Year (if applicable)
2023 School Attended (if applicable)
Email (if applicable)
example@example.com
Mobile Number (if applicable)
Medicare Number
Medicare Position on Card
E.g 1, 2, 3..etc in order of age
Medicare Expiry Date
E.g 02/2024
Please supply full details of any allergies or dietary conditions experienced by this child
Please supply full details of medications or medical conditions experienced by this child
Is there anything else that we should know about your child? (e.g. known behavioural issues).

Chandelier Transformations Youth Mentoring (CTYM) Registration Form

Payment Methods

Parent/Guardian #1

Parent/Guardian #2 (if applicable)

Alternative pick-up

Emergency Contacts

CHILD "1" INFORMATION

CHILD "2" INFORMATION

CHILD "3" INFORMATION