Youth Registration | Thea Bowman Center

YOUTH AFTER SCHOOL AND SUMMER K-8TH GRADE REGISTRATION

To register, please take the time to fill out the information below.

YOUTH INFORMATION

First Name

Last Name

Age

DOB

Address

City

Zip Code

Child's last grade completed

School name

PRIMARY CAREGIVER INFORMATION

Primary Care Giver Relationship (check):

Mother

Father

Grandparent

Other

If other, please enter relationship to youth.

Primary Care Giver Name: First, Last

Telephone

Email

Address

Secondary Caregiver (In case of emergency)

Secondary Care Giver Relationship (check):

Mother

Father

Grandparent

Other

If other, please enter relationship to youth.

Secondary Care Giver Name: First, Last

Telephone

Address

Email

Thea Bowman Center online Youth Program Parent Permission Form

By submitting this form, I give permission for my child to participate in the Thea Bowman Center’s
supervised After-School and Summer Program activities: Tutoring, Music, Martial Arts, Field Trips,
Black History and other learning activities. (Child must be in K -8 th grade)