Registration Form

Registration Form

Fill out the form carefully for registration. If the student is registering for any reading program listed below please have the student complete the appropriate assessment using the link provided to you after submitting the registration form. Registration form and Assessment must be completed in order for the student to be fully registered for the reading program.
Student Name*

First NameLast NamePreferred Name
Birth Date*

MonthDayYear
Gender*
Grade Level*
For 2025-2026 school year
School name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Name*

First NameLast Name
Parent Email*
example@example.com
Mobile Number*
I would like the student to participate in the following (Select all that apply):*

Developing Reading Confidence (Summer)Academic Excellence (Math)Academic Excellence (Reading)Sports Conditioning (Summer)Level Up (Reading)Level Up (Math)
Please provide all student availability (Ex: Monday/Morning or Tuesday/After 6p)*
Has the student completed an Assessment?*

YesNoIn Progress
Additional Comments
I would like to receive updates about free youth programs, events, opportunities, and more from a representative of Journey of Youth Development Inc.
Should be Empty: