Youth Registration Form
First Name
Last Name
Current Address
City
Zip
Select One
60620
60621
60619
60637
60636
Telephone Number
Email
Please provide your gender
Select One
Male
Female
Non-Binary
Please provide your race
Select One
African-American
Asian
Caucasian
Native-American
Multi-Racial
Native-Hawaiian or Pacific Islander
Please provide your ethnicity
Select One
Hispanic
Latino
Spanish Origin
Non-Hispanic
Birthdate
Please provide your primary language
Select
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English
Spanish
Other
Please list an emergency contact(s)
Please list the telephone number(s) of your emergency contact
ie.(xxx)xxx.xxxx;(xxx)xxx.xxxx
Please list any allergies or medical conditions. If you do not have any allergies or medical conditions, please indicate N/A in the field below
How did you hear about us?
Select
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Social Media
Email
Word-of-Mouth
School Counselor/Academic Advisor
Community Event
Other
Please select the primary service or resource you are seeking
Select
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Volunteer
Youth Events/Activities/Programs
Employment Resources/Services
Other