CTYM Registration Form

Chandelier Transformations Youth Mentoring (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: $30 (10 months)
Middle School Mentoring	6th-8th Grades	In person	Registration: Regular Registration Fee: $125 Monthly: Regular Price per month: $30 (10 months)
High School Mentoring	9th-12th Grades	In person	Registration: Regular Registration Fee: $125 Monthly: Regular Price per month: $30 (10 months)
Teen Summit	2022	TBD	TBD
Leadership Workshop	2022	TBD	TBD
CTYM FinTech Spring Break Camp (Girls Only) — Tampa, FL	March 16–20, 2026 Hours:Monday–Friday 8:00AM–5:00PM	📍 410 S. Ware Blvd, Suite 1038, Tampa, FL 33619	Registration Fee: $125 Cost for Camp: $125
CTYM NextGen Innovation Certification Academy (Girls Only)	June 15 – August 1, 2026 (7 weeks) Hours: Monday–Friday \| 8:00 AM – 5:00 PM	📍 410 S. Ware Blvd, Suite 1038, Tampa, FL 33619	Registration Fee: $150 Cost per week: $145

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

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

Group	School Year	When	Cost

Monthly Mentoring	2026-2027 4th -5th Grades 6th-8th Grades 9th-12th Grades	📍 410 S. Ware Blvd, Suite 1038, Tampa, FL 33619	Registration: Regular Registration Fee: $125 Monthly: Regular Price per month: $30
CTYM FinTech Spring Break Camp (Girls Only) — Tampa, FL	March 16–20, 2026 Hours:Monday–Friday 8:00AM–5:00PM	📍 410 S. Ware Blvd, Suite 1038, Tampa, FL 33619	Registration Fee: $125 Cost for Camp: $125
Teen Summit	2026	📍 410 S. Ware Blvd, Suite 1038, Tampa, FL 33619	TBD
Leadership Workshop	2026	📍 410 S. Ware Blvd, Suite 1038, Tampa, FL 33619	TBD
CTYM NextGen Innovation Certification Academy (Girls Only)	June 15 – August 1, 2026 (7 weeks) Hours: Monday–Friday \| 8:00 AM – 5:00 PM	📍 410 S. Ware Blvd, Suite 1038, Tampa, FL 33619	Registration Fee: $150 Cost per week: $145

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 #1
- First Name
- Last Name
- Address
- E-mail
- Phone Number
- Parent/Guardian #2 (if applicable)
- First Name
- Last Name
- 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)
- 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).
- 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).
- 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).
- Your registration summary:
  
  {firstNamechild1} {lastNamechild1}
  
  {2023CTYM}
  
  {firstNamechild2} {lastNamechild2}
  
  {2023CTYM}
  
  {firstNamechild3} {lastNamechild3}
  
  {2023CTYM}
- My completion of this form signals my willingness to permit my child(ren) to participate fully in Chandelier Transformations Youth Mentoring and any related activities.
- I give permission in the case of a medical emergency, to EMT, the Doctor or health care provider chosen (either by the CTYM authorities or other persons supervising or administering the activities), to secure proper treatment for and/or hospitalization, injection, anaesthetic or surgery for my child(ren) as named. I understand that every effort will be made to contact me prior to instituting such procedures.
- I give permission for my child(ren) to be photographed/filmed at activities during CTYM Activities and understand that these photos/videos may be displayed and used to promote the organization.
- Is there anyone legally restricted from seeing your child(ren)?
- If applicable, please provide details of anyone legally restricted from seeing your child(ren):
- I give permission for these details to be stored in a secure offline database:
- The Leadership team of the aforementioned group/s will treat the information contained confidentially. This information may be shared with a third party when it concerns medical health or care of individuals listed. If you wish to access this information or have queries in relation to the manner in which we handle your personal information, please do not hesitate to contact us.
- I confirm my agreement to all of these conditions:
  
  First NameLast Name
- Today's date
  
  DayMonthYear
  Date
- Kathy's Email
- Tacara's Email
  example@example.com
- My Products
- Coupon Code
- Registration Fee
- Monthly Fee
- Weekly Fee
- Should be Empty:

Chandelier Transformations Youth Mentoring (CTYM) Registration Form

My Products*

Payment Methods

Parent/Guardian #1

Parent/Guardian #2 (if applicable)

Alternative pick-up

Emergency Contacts

CHILD "1" INFORMATION

CHILD "2" INFORMATION

CHILD "3" INFORMATION

My Products

My Products