Teens Information
Child's Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Home Phone
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Female
Male
Patents/Guardian & Emergency Contact Information
Name
First Name
Last Name
Email
example@example.com
Relationship
Mother, Father, etc
Mobile Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Address
Same with the child
Different Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name
First Name
Last Name
Email
example@example.com
Relationship
Mother, Father, etc.
Mobile Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Address
Same with the child
Different Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact 1
First Name
Last Name
Relationship
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Emergency Contact 2
First Name
Last Name
Relationship
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Do you want to add something?
Marital status of parents, medical information, people who the child cannot be released, etc
There is a 10$ Enrollment Fee For The Program Due To Multiple Applications Being Submitted & Half Of The Teens Not Showing Up ! Payments Accepted Are Venmo , Cash App , Apple Pay , Square Payments
Type Your Full Name For Signature
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