SLYC Student/Youth Verification Form
Currently Registered Only
Student Information
Student 1 Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Name of School/College (up to age 22)
*
Currently enrolled School as of July 15, 2024
Current Grade
*
Enter grade level as of July 15, 2024
Student 2 Name (If none enter NA)
*
First Name
Last Name
Date of Birth (If none enter 11/11/1111)
*
-
Month
-
Day
Year
Date
Name of School/College (up to age 22) (if none enter NA)
*
Currently enrolled School as of July 15, 2024
Current Grade (If none enter 111)
*
Enter grade level as of July 15, 2024
Student 3 Name (If none enter NA)
*
First Name
Last Name
Date of Birth (If none enter 11/11/1111)
*
-
Month
-
Day
Year
Date
Name of School/College (up to age 22) (if none enter NA)
*
Currently enrolled School as of July 15, 2024
Current Grade (If none enter 111)
*
Enter grade level as of July 15, 2024
Student 4 Name (If none enter NA)
*
First Name
Last Name
Date of Birth (If none enter 11/11/1111)
*
-
Month
-
Day
Year
Date
Name of School/College (up to age 22)(if none enter NA)
*
Currently enrolled School as of July 15, 2024
Current Grade (If none enter 111)
*
Enter grade level as of July 15, 2024
Student 5 Name (If none enter NA)
*
First Name
Last Name
Date of Birth (If none enter 11/11/1111)
*
-
Month
-
Day
Year
Date
Name of School/College (up to age 22) (if none enter NA)
*
Currently enrolled School as of July 15, 2024
Current Grade (If non enter 111)
*
Enter grade level as of July 15, 2024
Parent Information
Parent/Guardian Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
Please enter a valid email address
Phone Number
*
Please enter a valid phone number.
Today Date
*
-
Month
-
Day
Year
Date
Parent Signature
*
Submit
Should be Empty: