Meet & Greet Registration
Youth Intake Form
Student's Name
*
First Name
Last Name
Student's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student's Age
*
Please Select
11 years old
12 years old
13 years old
Student's Gender
*
Male
Female
School Attending
*
Grade
*
Please Select
6th Grade
7th Grade
8th Grade
Parent/Guardian's Name
*
First Name
Last Name
Parent/Guardian's Home Phone
-
Area Code
Phone Number
Parent/Guardian's Cell Phone
*
-
Area Code
Phone Number
Parent/Guardian's Email
*
example@example.com
Relationship to Youth
*
Youth Interests
*
Art
Dance Photography
Gardening/Nature
Social Media
Video Games
Coding
Entrepreneurship
Music
Social Justice
Video/Filmmaking
Community Service
Financial Literacy
Public Speaking
Sports
Writing
What careers would you like to explore?
*
How did you hear about the program?
*
Please Select
from my school
from my friend/family
from a Sorority Member
from social media
from the YLI website
from church
Other
Did you participate in the program last year?
*
Yes
No
Submit
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