Endeavor Center
For Youth and Community Development
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REGISTRATION

ASSIST

3:00 pm - 5:30 pm on Tuesday and Thursdays

Complete this form once for each student who will be participating in the ASSIST program.

Student's Name *
Student's Name
Birthdate *
Birthdate
Address *
Address
Phone *
Phone
Mother's Name
Mother's Name
Phone
Phone
Father's Name
Father's Name
Phone
Phone
EMERGENCY CONTACT (other than parent/guardian) *
EMERGENCY CONTACT (other than parent/guardian)
Phone *
Phone
By typing your name in this box, you are agreeing to the following statement: I do hereby fully and freely consent to the use of participant’s photography for promotional purposes on both printed material, websites, and social media. I do hereby release and hold harmless the Endeavor Center from any liability out of said participation, advertisement, and/or promotion.