The Atlanta Forum – Registration

"*" indicates required fields

Personal information

Name*

First Last

Year in School*

Father's Name*

Mother's Name*

Email Address*

Email Address - Parent*

Address*

Street Address City State ZIP Code

Cell Phone Number*

Phone Number of Parent*

Date of Birth*

Miscellaneous

Which Center do you attend?*

Electronic Signature for Photo Release*

Parents must sign for applicants under 18 years of age.

I hereby authorize and consent to the use and reproduction by YSI staff or an authorized agent or assignee of any and all photographs taken of the above-named applicant for the purpose of promoting YSI programs, without any compensation to me. All images, together with any prints, shall constitute property of YSI, solely and completely.

Diet, Medical

Do you have any special dietary needs or medical conditions that we should be aware of?

Reference*

Who recommended this program to you?

Comments