EmailMe Form - Youth Program Registration Form

Date Time
MM / DD / YYYY
Parent/Guardian Name *
First Last
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Main Telephone *
### - ### - ####
Work Telephone
### - ### - ####
Cell Phone
### - ### - ####
Email Address *
Child's Full Name *
What school does your child attend?
What is your child's grade? *
Programs: select the program that you would like your child to participate in at The Youth Source Center *
After School Homework assistance program – ages 8-12
Oratorical training program – ages 12-17
Council of Youth Leadership – ages 12-17
Please read and initial: I give my informed consent and permission for my child to participate in the Youth Source Programs indicated above and its related activities. *
I agree to allow The Youth Source to use any photographic image of my child taken while participating in the mentoring program. Images may be used in promotions or other marketing materials. Please initial here *