Youth Night Registration

Youth Night Drop-In Registration Form

North Woodside Youth Night Drop-In Participant Information Form

* Indicates required field

Name of child/youth *

Birth Date *

Name of Parent/Guardian *

Parents Phone Number *

Emergency Contact Name (Different than Parent/Guardian) *

Relationship to Participant *

Parents Email *

Emergency Contact Phone Number *

Does the participate have special needs and/or require support? *

If Yes, please specify and include any information our facilitators may need to know *

Does the participant have any allergies? (Food, drug, environmental, etc.) *

If yes, does the treatment for this allergy involve the use of an epi-pen? *

By submitting this registration form for this participant, I am stating that I have read the policies of this program and understand that the participants actions must adhere to our code of conduct *

Submit