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ANGUILLA YOUTH EMPOWERMENT CLUB REGISTRATION FORM

Contact 584-1864
NAME: _________________________ BIRTHDAY: _____/_____/__________
I PREFER TO BE CALLED: _________________________________
ADDRESS: ____________________________________________ ____________________________________________ ____________________________________________
HOME PHONE: (_______) _______ - __________ CELL PHONE: (_______) _______ - __________
CURRENT SCHOOL: ________________________________ CURRENT GRADE______________
EMAIL: _______________________________________________________
ALLERGIES: ____ IF CHECKED PLEASE SPECIFY: _________________________________________________________________________________________
PARENT CONTACT:
MOTHER’S NAME: _______________________________ CELL PHONE: (_______) _______ - __________
MOTHER’S EMAIL: _____________________________________________________
FATHER’S NAME: ________________________________ CELL PHONE: (_______) _______ -__________
FATHER’S EMAIL: _____________________________________________________
EMERGENCY CONTACT: Please list an individual and phone number other than any that appear above.
NAME: __________________________________________ PHONE: (_______) _______ - __________
RELATIONSHIP: _________________________
ALL YOUTH MEMBERS ARE EXPECTED TO:
 Be punctual to all meetings
 Be respectful to all in attendance
 Contribute to youth activities
 Support the leaders and your peers with full participation
 Respect others as individuals giving the other person our undivided attention, listening politely and not ridiculing what other people say.
 Respect other's culture, race and background realizing that while we are all different, that deep inside we are essentially the same.
 Uphold the mission and vision of the organization
 Refrain from violence and use of drugs and alcohol
My parent and I understand the guidelines above.
Member signature: ________________________________________
Parent signature: ________________________________________
PHOTOGRAPHY/VIDEOGRAPHY WAIVER: I understand that my child may be photographed or recorded on video during the course of youth events. By initialing below I provide consent for his/her image to be used in either print, electronic, or video form for the promotional purpose of future retreats and youth group activities.
Initials of Parent/Guardian: _____________