For Youth and Community Development

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

First Name

Last Name

Birthdate

YYYY

Entering Grade

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Mother's Name

First Name

Last Name

Phone

(###)

###

####

Father's Name

First Name

Last Name

Phone

(###)

###

####

ACADEMIC INFORMATION (specific educational needs or challenges):

MEDICAL INFORMATION (Food Allergies or Other Special Needs):

EMERGENCY CONTACT (other than parent/guardian)

First Name

Last Name

Phone

(###)

###

####

SIGNATURE

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.

REGISTRATION

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

Where Dreams Begin and Lives Change