Youth Programs Registration
Student Name
*
First Name
Last Name
Student Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student Gender
*
Female
Male
Student Phone (if applicable)
Student Email (non-school email)
Student's Home Address, City and Zip Code
*
Address and zip code are required for participation.
Student's School
*
Student's Grade
*
Student's Race (Check all that apply)
*
Black/African American
Hispanic/Latino
Native American/American Indian
Asian/Pacific Islander
White/Caucasian
Other
Does student have any type of disability?
*
Yes
No
Not Sure
Which activities is student interested in? Check all that apply.
*
Youth leadership development
College/career exploration and field trips
Community service opportunities
Serve as youth sports coach volunteer
Youth sports - flag football, tackle football, basketball, soccer, cheer
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone
*
2nd Parent/Guardian Phone (if applicable)
Annual Household Income
*
Please Select
Under $25,000
$25,000 to $49,999
$50,000 to $74,999
Over $75,000
Total Number of People in Household
*
Download and read the
DHNS Youth Program Participation Waiver.
Signature - Please sign below.
*
Submit
Should be Empty: