top of page

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.)

Comment

Upload File

Upload File

Upload supported file (Max 15MB)

Rate our website...

Divine Assist
Ashland Virginia

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

Tax Exempt Letter
Terms of Use | Privacy Policy
© 2019 Divine Assist. All Rights Reserved.

Divine Assist
Ashland Virginia

Home
Mission
Donate
Hours of Operation
Youth Sign-Up
Black History Month

Divine Assist

bottom of page