Youth Program Registration Form

Choose program*
Girlz Space Session
Teen Leadership Camp
Participant Information
Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Date of Birth
MM slash DD slash YYYY
School
Grade Level
Email Address
Enter Email Confirm Email
Health Information
Any allergies, asthma, medical concerns or dietary restrictions we should be aware of?
Paren and Guardian Information
Parent/Guardian Name
First Last
Relationship to Child
Phone number
Email
Enter Email Confirm Email
Emergency Contact Name
First Last
Relationship to Child
Emergency Contact Number
Permissions - Check all that apply
- I give permission for my child to participate in this program.
- I give permission for my child to leave on her own at the end of the program.
- I will be picking up my child at the end of the program.
- The participant agrees to follow follow Women’s Habitat’s Code of Conduct
How did you hear about the program