Precious Pearls Youth Group Application

* You are required to upload the transcript, media, and affirmation files if completing the application online or a hard copy application packet may be submitted at the Open House meeting in August.

No incomplete form will be accepted.

Student Information

Name: *

Last Name First Name

Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number:

Area Code Phone Number

Cell Phone Number:

Area Code Phone Number

E-mail: *

Age: *

Date of Birth (mm/dd/yy) *

Grade Level: *

Current GPA: *

T-Shirt Size

Small, Medium, Large, XLarge, 2XLarge, 3XLarge

School Name: *

Community Service Hours:

Do you have an after-school job?

Yes No

If yes, where do you work?

How many hours per week?

List all extracurricular activities in which you participate:

Please list all Social/Community Groups in which you participate:

Parent/Legal Guardian Information

Parent/Guardian Name: *

Last Name First Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number:

Area Code Phone Number

Cell Phone Number: *

Area Code Phone Number

E-mail: *

Emergency Contact Information

In case of emergency contact: *

Last Name First Name

Home Phone Number

Area Code Phone Number

Cell Phone Number

Area Code Phone Number

Relationship to Student: *

Do you have any allergies or health concerns that we should be aware of?

* The Media Release and Affirmation files can be found on akagto.com.

Upload Transcript: *

Upload Signed Media Release File: *

Upload Signed Affirmation File: *