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* 1. Parent/guardian name(s):

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* 2. Parent/guardian email(s):

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* 3. Emergency contact phone number:

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* 4. Youth name(s) and birth dates

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* 5. Home address (for care package delivery)

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* 6. Another home address? (if applicable) 

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* 7. PO Box (for potential prize delivery)

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* 8. What would you (and/or your child) be interested in seeing from the Youth Centre?

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* 9. The Queen Charlotte Youth Centre will keep all of your information private. Do you give consent for us to use pictures of your child(ren) for communication/promotion purposes?

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