I'RAISE Girls & Boys International Corporation Virtual Youth Services Application
Section I

Our Virtual Activity services provides opportunities for children to stay occupied while at home during COVID-19. Children are able to acquire new skills and meet new friends. Each of our virtual activities are conducted by one of our experienced faciliatator/specialist.
Child First and Last Name *
Your answer
Child DOB *
MM
/
DD
/
YYYY
Child Gender *
Child Home Address *
Street Number, Borough, Zip Code, State
Your answer
Which best describes the race/ethnicty of your child? *
Required
School Child Attends *
Your answer
Grade Child is in? *
Your answer
Does any of the following apply to your child: *
Required
Parent/Gaurdian Name (First and last name) *
Your answer
What is your relationship to the child. *
Parent/Gaurdian Address (If same as child. please indicate "same as child" below) *
Street Address, Zip Code, Borough, State
Your answer
Parent /Gaurdian Mobile Number *
Your answer
Parent/Gaurdian Email Address *
Your answer
Which best describes the race/ethnicty of the parent/gaurdian completing this form? *
Primary Language Spoken at Home *
Do you currently receive any of the following benefits for yourself or your child/ren? *
Does child have access to Both an electronic device and wireless connection at home to connect to virtual sessions? *
Please select the virtual activity group you would like to enroll your child in: *
Each session is one hour long. Please select as many as you are interested in enrolling your child in.
Required
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