Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (or guardian's phone) *

(###)

###

####

Parent or Guardian Name *

First Name

Last Name

Emergency Phone *

(###)

###

####

Parent or Guardian Phone *

(###)

###

####

Program *

WHIZ-KIDZ (elementary) Wednesdays 3:30 pm to 5:30 pm

DISCOVERY/JOURNEY (middle/high school) Mondays 5:30 pm to 7:30 pm

DISCOVERY/JOURNEY (middle/high school) Tuesdays 3:30 pm to 5:30 pm

Do you authorize Freedom for Youth to produce photographs, videos, and presentations that include images of your child.

Yes

No