Youth & Family Registration

Please fill out this form so your child can participate in our Youth Program. Thank you!

Student #1

Student 1 Name

*

Nickname/Preferred Name (if applicable)

Student 1 Birthdate

*

Student 1 Gender

Please select one option.

Female Male Non-Binary

Student 1 Phone

Student 1 Email

Student 1 Lives with:

Student 1 School

Student 1 Grade

Student 1 Allergies

*

Student 1 Medical Conditions

Student 1 Special Needs

Student 1 Interests, Activities, Work (teens)

Talents others see that your youth may not recognize in self

Student #2 - Scroll down for parent info if you are not enrolling other children.

Student #2 Name

Nickname/Preferred Name (if applicable)

Student #2 Birthdate

Student #2 Gender

Please select one option.

Female Male Non-Binary

Student #2 Phone

Student #2 Email

Student #2 Lives with:

Student #2 School

Student #2 Grade

Student #2 Allergies

Student #2 Medical Conditions

Student 2 Interests, Activities, Work (teens)

Talents others see that your youth may not recognize in self

Student 3 - Scroll down for parent info if you are not enrolling other children.

Student 3 Name

Student 3 Nickname

Student 3 Birthdate

Student 3 Gender

Please select one option.

Female Male Non-Binary

Student 3 Phone

Student 3 Email

Student 3 Lives with

Please select one option.

Mom Dad Mom & Dad other

Student 3 School

Student 3 Grade

Student 3 Allergies

Student 3 Medical Conditions

Student 3 Interests, Activities, Work (teens)

Talents others see that your youth may not recognize in self

Permissions

Do we have your permission to take your child/ren’s picture in the classroom?

*

Please select one option.

Yes No

Do we have your permission to post your child/ren’s picture on social media?

*

Please select one option.

Yes No

Do we have your permission for your child/ren to be on camera if at the front?

*

Please select one option.

Yes No

Parent/Guardian #1
This should be the person who brings the child to UnityCR.
(could be grandparent/family member/friend designated by parent.)

Name

*

Relationship to Child

*

Email

*

This address will receive a confirmation email

Phone

*

Address

*

Parent/Guardian #2
Additional guardian or parent.

Parent/Guardian #2 Name

Relationship to Child

Parent/Guardian #2 Phone

Parent/Guardian #2 Email

Parent/Guardian #2 Address

Description

Please fill out this form so your child can participate in our Youth Program. Thank you!

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