Youth Name:
Email Address:
Mailing Address:
City, State, Zip:
Home Phone:
Cell Phone:
Screen Name:
Birth Date:
Grade in Fall 2009:
Gender:	Male   Female
Race/Ethnicity:
Parent's Name(s):
Mailing Address: (if different from child)
City, State, Zip: (if different from child)
Home Phone: (if different from child)
Cell Phone:
Email Address: (if different from child)
Current Pact Family Member?	Yes   No
Are you already a Teen Club Member?	Yes   No
Please tell us who in your family will be attending:
Will parent attend parent group?	Yes   No
If you will need child care for children younger than 10, give us their information below:
Child Name & Birth Date
Child Name & Birth Date
Child Name & Birth Date
Please list any issues, concerns or ask any questions you may have here: