Senyah Youth Registration Form

Senyah Youth Registration Form
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   Date*

First Name*   Last Name*

Parent/Guardian*   Relationship to Youth*

Street Address*      City*   State*   Zip*

Home Phone*   Cellphone*   Email*

Age*   DOB*

   *      *

Name of School District*   Name of School*   Grade*

EMERGENCY CONTACT INFORMATION:
First Name*   Last Name*   Relation*        Phone Number*

First Name*   Last Name*   Relation*      Phone Number*

Registration Dues *
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2022-2023 Registration Includes One Year Registration, 2022-23 Senyah tshirt and bottle
$ 50.00

Total

$ 0.00
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Credit Card Number	Security Code
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