Ivymount Outeach Returning Participant Application

Ivymount Outreach Returning Participant Application

Participant Information

First Name:    

Last Name:    

Date of Birth:   

Street Address:   

Address Line 2:    

City:   

State/Province/Region:   

Postal/Zip Code:   

Participant lives with:       Other please specify:   

Check the programs you are interested in the participant attending:

  Fall Athletics Tuesdays AND Thursdays

  Fall Athletics Tuesdays ONLY

  Fall Athletics Thursdays ONLY

  Fall Art Tuesdays AND Thursdays

  Fall Art Tuesdays ONLY

  Fall Art Thursdays ONLY

  Girls Club Fall II Session (Nov 4th - Dec 16th)

  Camp LOL Fall II Session (Nov 4th - Dec 16th)

  Unstuck and On Target (session starting in January, requires a $50 application fee)

  Mythbusters (session starting in January)

  Game Time (session starting in January)

  Secrets of Friendship (session starting in January)

  Conversation Club/Street (session starting in January)

Parent/Guardian Information

Parent/Guardian 1 

Name:   

Relationship to participant:   

Street Address:   

Address Line 2:   

City:   

State/Province/Region:   

Postal/Zip Code:   

Primary Phone Number:   

Alternate Phone Number:   

Email:   

Preferred Contact Method:   

 

Parent/Guardian 2 

Name:   

Relationship to participant:   

Street Address (if different than above):   

Address Line 2:   

City:   

State/Province/Region:   

Postal/Zip Code:   

Primary Phone Number:   

Alternate Phone Number:   

Email:   

Preferred Contact Method:    

Click "Submit" below to complete your application.

 

Please note that applications for Unstuck and On Target require a non-refundable, $50 application fee.   After submitting your application, please click on the "Pay Now" button to submit this fee. 



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