Empower Youth Application

Empower Youth Application

Part I - Personal Information
Cultivate Fertile Minds Application

YOUTH SUMMER CAMP
Applicant Name*

First NameLast Name
Child Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
XSSMLXL
Allergies:
How did you hear about us?*
Part II - Parent/Guardian
Parent Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Email Address*
Part III - Education
School Name*
Location*
Current Grade*
Part IV - Additional Children (To enroll in program)
Child Name

First NameLast Name
Child Age*
XSSMLXL
Allergies:
Emergency Contact:
YesNo
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Youth Summer Camp - Week 4
Register youth 5-13 for our summer camp today!! $125 a week

$125.00 Quantity
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Youth Summer Camp - Week 5
Register youth 5-13 for our summer camp today!! $125 a week

$125.00 Quantity
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Youth Summer Camp - Week 6
Register youth 5-13 for our summer camp today!! $125 a week

$125.00 Quantity
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Youth Summer Camp - Week 7
Register youth 5-13 for our summer camp today!! $125 a week

$125.00 Quantity
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Youth Summer Camp - Week 8
Register youth 5-13 for our summer camp today!! $125 a week

$125.00 Quantity
Item subtotal:$0.00



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