King Me Registration Form

Course Begins: Thursday, April 4, 2024 from 5:30pm-7:00pm

Location: Boys & Girls Club of Stamford 347 Stillwater Ave Stamford, CT 06902 *HIGH SCHOOL BOYS ONLY*
Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Please select "N/A" if you do not identify with the options listed.
If you selected "N/A" please tell us how you identify.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail*
example@example.com
Mobile Number*
School*
Grade*
Age*
Course*
T-shirt Size*
Hey, King! What do you hope to gain/ learn from this course?*
This course is for you, even if you do not identify as a "KING"
What should we know about you?
Example: Are you shy or outgoing? Do you want to meet new friends? Do you have any struggles we can help with (i.e. self esteem, body image, confidence, job search, conflict resolution etc)? Feel free to share as much as you can, we are here to help!
Are you interested in an overnight retreat?

YesNoMaybe
How did you hear about this course?

FriendFamily MemberMentorSocial MediaSchoolOther
If other, tell us how.
Will you be able to commit to us every Thursday starting April 4th - May 30th from 5:30pm to 7pm (8 weeks)?

Guardian/Emergency Contact Information