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Youth Sign-Up Form

Parent Name

First Name

Last Name

Parent Email Address

Parent Phone Number

Address

City

State / Province

Youth Name

First Name

Last Name

Age

Grade

School Name

How did you find out about this program?

Emergency Contact

Name

Alergies

Phone Number

Relationship

Do you give us permission to share a photo of you on our website and or social media?

Yes

No

Signing up for...

Recreation - Game Area/Arcade

Mentoring

Tutoring

Youth Counseling

Karate Age 5 - 17

Basketball - Training

Reading Program

Contiued...

Chess Club

Computer - Coding

Computer - Typing

Program - Boys 2 Men

Program - Girl Power

Youth Volunteer

College Student Credit Hrs

* (Parent/s will recieve information/reminders regarding youth group activities and events only.)

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Divine Assist
Ashland Virginia

406 Myrtle St.
Ashland VA. 23005
Phone: (804) 315-2756
Email: divineassist@divineassist.org

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Divine Assist
Ashland Virginia

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