Junior Youth ProgramRegistration Form Name of participant * First Name Last Name Date of Birth * MM DD YYYY Home address * Applicants are required to reside and/ or attend school in North Poco School * Name of Parents/Guardians * First Name Last Name Email * Phone * (###) ### #### Which day are you available? * Monday - After School Tuesday - After School Wednesday - Afterschool Thursday - Afterschool Friday - Afterschool Saturday - Morning Sunday - Morning Does your junior youth have any allergies dietary illness disability or other medical conditions * How did you hear about the programs * Do you permit the use of the photos and videos taken of the camps activities that include your son/daughter to be used in the programs promotional materials Yes No I hereby give permission for my son/daughter to attend this program. I understand that the Junior Youth Empowerment Program will endeavor to provide my son/daughter with a safe environment. In the case of personal injury, loss or damage I, or a third party, will not hold Junior Youth Empowerment Program, its agents or volunteers responsible. * Yes Pickup: After each session I will pick up my son/daughter My son/daughter will walk home Thank you for registering!
