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Soomaali
WWPSC Integrative Youth Program — Enrollment Form
SUMMER 2026 · BLOOMINGTON, MNIntegrative Youth ProgramIntake FormComplete this form to enroll your child in our summer program. This information helps us prepare the right support for your family — it takes about 8–10 minutes.
Your child's name
First Name
Last Name
Program age group
Group A -Roots and Rising (8-12)
Group B- Voice and Vision ( 12-16)
Parents/Guardian
Parents Information
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Consent & Agreement
Check all boxes below to confirm your agreement.
I give permission for my child to participate in all program activities.
I give permission for photos and videos to be taken for program use.
I have read and agree to the program guidelines and policies.
Parent Signature
Submit
Submit
Should be Empty: