Youth Media Pathways Program Registration

Youth Media Pathways Program Registration

Register to join the one-year youth media program, starting 5/23/2026 and one Saturday each month following the original date. Please prepare your personal and medical information to complete the registration. You must have your own transportation to and from program.
Participant's Full Name

First NameLast Name
Date of Birth (Ages 10-17 only)

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
School Attended
Please list any food allergies
Please list any medical conditions
Emergency Contact
Emergency Contact Full Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Should be Empty:

Emergency Contact