Pathway To ReJoyce -Registration Form

1
We have 2 different sites. Please select the Location closest to you
The R.E.C 16326 Harper Ave Detroit MI 48224
Carruthers Activity Center 21000 Ascension Rd Warren Mi 48089
2
Student Name* This field is required.
First Name
Middle Name
Last Name
3
Cell Phone Number
Area Code
Phone Number
4
Email
example@example.com
5
Gender* This field is required.
Please Select
Please Select
Male
Female
N/A
6
Name of School youth attend
7
Grade Attending must be 6-12* This field is required.
Please Select
Please Select
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th grade
8
Does your child need any accommations or support to help her/she participat fully? If so please list them below
9
Parent/Guardian Name
First Name
Last Name
10
Cell Phone Number
Area Code
Phone Number
11
Parent/Guardian (1) E-mail* This field is required.
12
We welcome volunteers, donors, and sponsors who want to help us continue providing free programs and support to youth and families in our community. We are always in need of paper plates, cups, plastic silverware, paper towels, bottled water , hand sanitizer, snack, chips. Will you commit in supporting us in any way you can
Yes, I will commit to donating supplies or snacks
I would love to, but I cant commit at this time
I would love to volunteer as a mentor, please contact me
13
Parent/Guardian Signature
Should be Empty: