Middle School Boys Session Sign-Up 🎉🤝
Register your son for the upcoming small-cohort summer program and secure his spot.
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best way to reach you
Call
Text
Email
Participant's (Son's) Full Name
*
First Name
Last Name
Grade entering this fall
*
6th grade
7th grade
8th grade
Participant's age
School Name
This program meets Mon & Wed — July 27 & 29, Aug 3, 5, 10 & 12 — from 9:00–11:00 AM.
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Allergies, medical conditions, or medications we should know about
Any learning, behavioral, or accommodation needs we should be aware of
What are you hoping your son gets out of this program?
I give permission for photos/video of my son taken during the program to be used in A Chance 4 Change promotional materials.
Yes
No
How did you hear about us?
Friend/Word of mouth
Social media
Flyer
School
Other
Anything else you'd like us to know?
Participant's Date of Birth
*
-
Month
-
Day
Year
Date
T-Shirt Size
*
Please Select
Youth S
Youth M
Youth L
Adult S
Adult M
Adult L
Adult XL
Who is authorized to drop off and pick up your son? (List names)
*
Reserve His Spot
Should be Empty: