FREE. Child must attend 1st session in order to attend the second session.
Age 7-17. Snacks Provided. Parent DropOff.
Saturday April 13 & 20th. 10:00am- 12:30pm
661 Lincoln St, Portsmouth, VA 23704
Parent Legal Name
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First Name
Last Name
Parent Phone Number
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Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child Date of Birth
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Month
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Day
Year
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Child Name
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First Name
Last Name
Child Date of Birth
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Day
Year
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Child Name
First Name
Last Name
Parent E-mail
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Allergies?
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I hereby authorize Care for Me Youth Initiatives/ Shekita Jackson/Impacted Life Church of VA to utilize all information contained in this application for program purposes. I release all such persons or entities from all liability. I agree to photos and videos taken of the program which will contain all adults and children listed in this registration, I agree that photos and video can be used for funding purposes. I understand that this personal information will be held confidential by Shekita Jackson/Care for Me Youth Initiatives/volunteers & staff.
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