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Youth Rising Drop-In Center Registration Form
We require each youth participating in activities to be registered by a parent or guardian after the first visit if under age 18. Youths 18+ may register on their own behalf. The following information should be provided by the appropriate party and then updated as necessary. All information will be kept confidential. 

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Email *
Which Drop-In Location? *
Section 1: Youth Information
Youth Full Legal Name *
Youth Preferred Name
Youth Date of Birth *
MM
/
DD
/
YYYY
Youth Age
Youth Gender *
School & Grade (e.g., "Hobbs High, 10th Grade") *
Youth Contact Information (Cell Phone & Email) *
Youth Home Address (Street Address, City, State, Zip Code) *
Youth Race *
How did you first hear about Youth Rising? *
Were you referred by another youth to register today? *
If YES:
What is the full name of the youth who referred you?
(Make sure to enter their FIRST and LAST name so they receive raffle entries for referring you!)

Which of the following have you completed? (Select all that apply)

Description:

Complete these actions to earn raffle entries:
• Follow us on Instagram: 
• Follow us on Facebook:
• Sign up for our newsletter: 

Clear selection
Free/Reduced Lunch Status (Does the youth qualify for free or reduced lunches at school?) *
Section 2: Medical & Safety Information
Medical Conditions & Allergies (List any allergies or medical conditions our staff needs to be aware of. Write "None" if not applicable.) *
Primary Care Physician (Name & Phone)
Mental Health Services (Is the youth currently receiving mental health services? If yes, please list where/which services.)
Section 3: Parent & Emergency Contact
Parent/Guardian Full Name *
Parent/Guardian Contact Info (Cell Phone, Home Phone, and Email Address) *
Parent/Guardian Address (Leave blank if the same as Youth Address)
Emergency Contact (Non-Parent - Name, Phone Number, and Relationship to youth) *
Section 4: Permissions & Releases
*
Yes (I Consent/Agree)
No (I Do Not Consent)
Media Release: Permission to use youth's name/photo in press/marketing materials/social media.
Movies: Permission to view PG/PG-13 movies deemed appropriate by staff.
Gaming: Permission to play video games rated T (Teen) or below.
Clubs/Activities: Permission to participate in various clubs (Art, Culinary, Skill-building, etc.).
Surveys: Permission to participate in anonymous surveys and/or screenings for resources during drop-in hours.
Emergency Medical: Authorization for staff to consent to emergency treatment if parent cannot be reached.
Peer Support: Permission to access support groups. I understand confidentiality cannot be guaranteed in groups.
Pick-Up Policy: I agree to pick up youth by closing time. Late pickups may result in suspension.
Volunteers: I agree to allow youth to interact with background-checked volunteers.
Youth Rising program of interest *
Parent Volunteer Interest (Optional - Check if you are interested in helping out!)
Electronic Signature (Type your name and the date below to certify you are the parent/guardian or 18+ and agree to the stipulations above. e.g., "Jane Doe 11/26/2025") *
A copy of your responses will be emailed to the address you provided.
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