WDCAC Youth Program Application

Submission Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Program you are applying for:
Short Program Name
Have you previously participated in one of our Youth Programs?
Which program? Select all that apply.
Which year? Select all that apply.
Section I: Applicant Information
Applicant Name
Applicant Address

Street Address Line 2
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Applicant Home Phone
Format: (000) 000-0000.
Applicant Mobile Phone
Format: (000) 000-0000.
Applicant Email Address
School Currently Attending
School Address

Street Address

Street Address Line 2

Zip Code
Grade Level
Youth's Shirt Size
Section II: Parent/Guardian Contact Information
Name of Parent/Guardian 1
Address - Same as applicant?
Parent/Guardian 1 Address (if different from applicant)

Street Address Line 2
Parent/Guardian 1 Email Address
Parent/Guardian 1 Home Phone
Format: (000) 000-0000.
Parent/Guardian 1 Mobile Phone
Format: (000) 000-0000.
Parent/Guardian 1 Other Phone
Format: (000) 000-0000.
Name of Parent/Guardian 2
Address - Same as applicant?
Parent/Guardian 2 Address (if different from applicant)

Street Address Line 2
Parent/Guardian 2 Email Address
Parent/Guardian 2 Home Phone
Format: (000) 000-0000.
Parent/Guardian 2 Mobile Phone
Format: (000) 000-0000.
Parent/Guardian 2 Other Phone
Format: (000) 000-0000.
Section III: Favorite Subject, Activities, Talents/Hobbies Interests

Complete this section if applicable.
List any special talents and/or hobbies
List favorite school subject(s)
List extracurricular activities (e.g., school, community, church-related, etc.)
Subject(s) that you need/want to improve
Honors/Awards/Achievements
List suggested topics that you would like to discuss this year
List activities or community service projects that you would like to do this year
How did you hear about our youth programs?
Section IV: Parental Consent (To be signed by Parent/Guardian only)
Acknowledgement - Parent/Guardian Signature denotes approval for your child to participate.
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
For additional questions regarding a youth program, contact:

Delta Academy - DeltaAcademy@wdcacdst.org

Delta GEMS - GEMS@wdcacdst.org

EMBODI - EMBODI@wdcacdst.org
Should be Empty:

Section I: Applicant Information

Section II: Parent/Guardian Contact Information

Section III: Favorite Subject, Activities, Talents/Hobbies Interests

Section IV: Parental Consent (To be signed by Parent/Guardian only)