Drug Free Youth (D-Fy) Membership Application

Drug Free Youth (D-Fy) Membership Application
Date*

MonthDayYear
Date
Please select one:*

New MemberRenewing Member
Name*

First NameLast Name
Youth's Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Youth's Phone Number

Area CodePhone Number
Ethnicity
Ex: Asian
Please provide a method of contact for your parent or guardian (email OR phone #)
Parent Email
example@example.com
Parent Phone Number

Area CodePhone Number
School: *
Grade: *
Date of Graduation:*
Would you like to receive texts about D-Fy activities, volunteer opportunities etc.?*

YesNo
I am at least 12 years old*

YesNo
I understand that a drug-screening is part of my application porcess. The screening will be conducted at no charge to me as the final part of my application or renewal.

I cetifiy that I am at least 13 years of age. I also understand that if I am under 18, a parent or guardian has the right to request my test results. I understand that if my results indicate i have used alcohol, niccotine or other drugs, my application will not be processed for membership and a D-Fy representative will provide me with options on how to re-apply.

I understand that annual renewel is required to maintain my membership and that I may be subject to random testing thoughout my membership. I undertand that my membership will be cancelled if I refuse requests for future screenings or engage in any unlawful activities.
Signature

Clear
Thank you for pre-registering for D-Fy. A staffmember will contact you shortly to set up a date and time when you will complete your memberhsip by taking a drug screening and receiving your ID card. In the meantime, please "like" us on Facebook.
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