Chagrin Valley Islamic Youth (CVIY) Registration Form
2018--2019
Email address *
Please provide primary email address for the new youth member above.
Youth Member's Name (First and Last) *
Your answer
Youth Member's Phone Number *
Your answer
Youth Member's Home Address (Street, City, State, Zip Code) *
Your answer
Youth Member's Age *
Any Allergies (If none, please write "None".) *
Your answer
Any Heath Issues (If none, please write "None".) *
Your answer
Parent 1: Name *
Your answer
Parent 1: Phone Number *
Your answer
Parent 2: Name
Your answer
Parent 2: Phone Number
Your answer
Parent's Email Address *
Your answer
Parental Consent *
Required
Questions/Concerns?
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