YICG Online Registration Form - 2020-21
YICG Office & Resource Center
999 Herricks Road, Suite 110
New Hyde Park, NY 11040

yicgroup99@gmail.com www.yicg.com Fed 501©3 Id: 11-3256075
Email address *
Adult Full Name (First & Last Name) *
Have you registered with us before? *
What best describes your relationship to this account? *
Mobile Phone Number (XXX-XXX-XXXX) *
Emergency Contact Name - For Account *
Emergency Contact Number - For Account (XXX-XXX-XXXX) *
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Registering a Child, Adult or Both? *
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