YSLI Innovators Program Registration Form

YSLI Innovators Registration Form

Young Successful Leaders Entrepreneurship Program
Youth Information
Youth Name

First NameLast Name
Birth Date

MonthDayYear
Email Address
example@example.com
School Name
Grade
Gender
Youth Name

First NameLast Name
Birth Date

MonthDayYear
Email
example@example.com
School
Grade
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.
T-Shirt Size
Are you registered through Civic Recs with Baltimore City Recreation & Parks
Will you need transportation provided?
Youth Signature
Parent Signature
Should be Empty:

YSLI Innovators Registration Form