CYEP “Project Success” Registration Form
PARTICIPANTS MUST HAVE PERMISSION FROM PARENT OR GUARDIAN IN ORDER TO PARTICIPATE IN THE PROGRAM.

If you have questions, contact Shaheed Patterson at (571) 366-7153 or email: spatterson@cyep.org

Capital Youth Empowerment Program
1315 Duke Street
Alexandria, VA 22314
www.cyep.org

Date *
MM
/
DD
/
YYYY
Child's Name (First and Last) *
Your answer
Child's Date of Birth
MM
/
DD
/
YYYY
Name of Parent Giving Permission (First and Last Name) *
Your answer
Best Contact Phone Number (Parents will be contacted to verify online registrations) *
Your answer
Parent Email Address
Your answer
Address (Street, City and State) *
Your answer
Location of Project Success Group *
My child has my permission to participate in CYEP’s “Project Success”, in collaboration with the Alexandria Campaign on Adolescent Pregnancy (ACAP). *
I consent and authorize the reproduction and use of myself or my child’s images. These images may be used for advertising, commercial, recruitment or education purposes in videotapes, photograph pictures, or art sketches in connection to CYEP. *
I allow my child to attend sessions which involve age appropriate information relating to human development, HIV risk reduction & pregnancy prevention. I understand that I can review the class materials at any time and can discuss any concerns I may have with CYEP staff. *
I have read and understand the information given above. I voluntarily answered each statement on this consent form. *
Please List Your Child's Allergies or Medical Conditions Our Staff Should Be Aware of: *
Your answer
Household Income
Your answer
Female Head of Household?
TANF Elgible?
Submit
Never submit passwords through Google Forms.
This form was created inside of Capital Youth Empowerment Program. Report Abuse - Terms of Service - Additional Terms