Limitless Youth Registration 2023

Youth Program Options*

Cook It Up!
Go Rec It!
Kid Tech Nation
Youth Internship

Youth's Information

Child's Name*

First Last

Child's Address*

Street Address City Postal Code

Child's Birthdate*

Child's Birthdate

*

Gender

Parent / Guardian Contact Information

Mother / Guardian*

Name Cell# Work#

Child's Address*

Street Address City Postal Code

Mother / Guardian Email*

Email

Parent / Guardian Contact Information

Father / Guardian*

Name Cell# Work#

Child's Address*

Street Address City Postal Code

Father / Guardian Email*

Email

Parent/Guardian with legal custody*

*If there is a custody order please include a copy with your registration

Emergency Contact Information

Emergency Contact (Cannot be Mother or Father, must have a local address)

Emergency Contact Name*

Name Cell# Work#

Emergency Contact Address*

Street Address City Postal Code

Additional people who may pick up your child:

Medication Required (epi pen, puffer, etc.)?*

Yes
No

Medication Required Type

Relevant Health information (Medical Condition (s))?*

Yes
No

List Medical Condition(s):

Does your child have any pre-existing conditions that may present as influenza like symptoms? Ex: Allergies, chronic cough, etc*

Yes
No

List pre-existing Condition(s):

Allergies?*

Yes
No

Allergies please list:

List pre-existing Condition(s):

Inclusive care needed? (If Yes, interview required)*

Yes
No

Dietary restrictions please list:

Cultural Background:

Please list any other relevant information:

I agree:*

CAPTCHA

Limitless Youth Registration 2023

Program Registration 2023 - Limitless Youth

Youth's Information

Parent / Guardian Contact Information

Parent / Guardian Contact Information

Emergency Contact Information