2020 LYD Youth Application
Youth's Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address (Street, City, State, Zip Code) *
Your answer
School *
Your answer
Grade *
Home Phone (including area code) *
Your answer
Cell Phone (including area code)
Your answer
Mother's Name *
Your answer
Mother's Phone/Cell
Your answer
Mother's Work Phone
Your answer
Mother's Email
Your answer
Father's Name *
Your answer
Father's Phone/Cell
Your answer
Father's Work Phone
Your answer
Father's Email
Your answer
I wish to enroll in the following Camps and programming offered by Lakota Youth Development/ Wicozani Patintanpi Prevention Activities: *
Required
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