YOUTH IMPACT PROGRAM
Please fill out this form to register your child for our after school program. If you have more than one child, we ask that you fill out an additional application for each child. Monday's: 3:30-5:30 Grades 1-6 Wednesday's:3:30-5:30 Grades 7-10
Student's Name
First Name
Last Name
Student's Age
Date of birth mm/dd/yy
What grade is your child in?
September 2024-June 2025
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Conditions
Allergies
Authorized Pickup Persons
Parent/Guardian
Other
*The Youth Impact Program staff uses photos and videos of the children on our social media platforms. These images and videos help us promote our programs and celebrate the achievements of your children. Do you consent to the use of your child's photos and videos on our social media platforms for promotional purposes?*
Yes, I consent to the use of my child's photos and videos
No, I do not consent to the use of my child's photos and videos
Does your child have permission to walk home?
YES
No
How did you hear about Youth Impact Program?
Please Select
School
Friends/Family
Online
Other
Additional Comments
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: